| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
553 |
530 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
216 |
212 |
$9K |
| D1110 |
Prophylaxis - adult |
282 |
273 |
$7K |
| D0330 |
Panoramic radiographic image |
205 |
199 |
$7K |
| D1206 |
Topical application of fluoride varnish |
340 |
339 |
$4K |
| D1120 |
Prophylaxis - child |
155 |
152 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
28 |
$3K |
| D0274 |
Bitewings - four radiographic images |
153 |
130 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
16 |
$1K |
| D1351 |
Sealant - per tooth |
51 |
13 |
$851.00 |
| D0120 |
Periodic oral evaluation - established patient |
27 |
25 |
$348.04 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
26 |
$206.73 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$206.16 |