| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
437 |
433 |
$30K |
| D1120 |
Prophylaxis - child |
539 |
536 |
$29K |
| D1351 |
Sealant - per tooth |
534 |
111 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
729 |
727 |
$23K |
| D1110 |
Prophylaxis - adult |
289 |
289 |
$21K |
| D0274 |
Bitewings - four radiographic images |
379 |
379 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
420 |
418 |
$17K |
| D0272 |
Bitewings - two radiographic images |
442 |
439 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
41 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
405 |
398 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
332 |
326 |
$7K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$2K |
| D1206 |
Topical application of fluoride varnish |
22 |
21 |
$577.92 |
| D0603 |
|
38 |
38 |
$0.00 |
| D0602 |
|
553 |
550 |
$0.00 |
| D0601 |
|
97 |
97 |
$0.00 |