| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
684 |
677 |
$22K |
| D1110 |
Prophylaxis - adult |
572 |
570 |
$13K |
| D0274 |
Bitewings - four radiographic images |
496 |
495 |
$8K |
| D0330 |
Panoramic radiographic image |
196 |
196 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
236 |
235 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
454 |
454 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
62 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
37 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
113 |
$2K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$1K |
| D1351 |
Sealant - per tooth |
78 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
103 |
$794.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$502.00 |