| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
621 |
611 |
$17K |
| D1110 |
Prophylaxis - adult |
290 |
286 |
$17K |
| D1120 |
Prophylaxis - child |
430 |
427 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
368 |
$14K |
| D0330 |
Panoramic radiographic image |
165 |
165 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
231 |
229 |
$13K |
| D0272 |
Bitewings - two radiographic images |
337 |
331 |
$9K |
| D0274 |
Bitewings - four radiographic images |
173 |
173 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
126 |
124 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
300 |
297 |
$6K |
| D1351 |
Sealant - per tooth |
194 |
55 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
198 |
178 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
30 |
$4K |