| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
979 |
863 |
$22K |
| D0330 |
Panoramic radiographic image |
444 |
401 |
$18K |
| D1120 |
Prophylaxis - child |
679 |
587 |
$11K |
| D1206 |
Topical application of fluoride varnish |
401 |
354 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
362 |
324 |
$5K |
| D1351 |
Sealant - per tooth |
232 |
54 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
17 |
$2K |
| D1110 |
Prophylaxis - adult |
49 |
45 |
$1K |
| D0240 |
|
201 |
54 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
328 |
100 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
17 |
12 |
$864.00 |
| D0220 |
Intraoral - periapical first radiographic image |
197 |
171 |
$645.00 |
| D0272 |
Bitewings - two radiographic images |
53 |
49 |
$370.00 |