| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,548 |
1,498 |
$110K |
| D4355 |
|
404 |
396 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,832 |
538 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
242 |
235 |
$14K |
| D0330 |
Panoramic radiographic image |
1,958 |
1,899 |
$13K |
| D1110 |
Prophylaxis - adult |
1,442 |
1,404 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
362 |
144 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,522 |
1,497 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
74 |
$1K |
| D0274 |
Bitewings - four radiographic images |
939 |
922 |
$1K |
| D1330 |
|
1,801 |
1,749 |
$795.14 |
| D4341 |
|
34 |
12 |
$558.00 |
| D1351 |
Sealant - per tooth |
92 |
15 |
$174.02 |
| D1206 |
Topical application of fluoride varnish |
215 |
195 |
$81.79 |
| D1120 |
Prophylaxis - child |
56 |
56 |
$40.32 |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
41 |
$4.02 |