| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
352 |
350 |
$16K |
| D0274 |
Bitewings - four radiographic images |
559 |
550 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
490 |
477 |
$13K |
| D1120 |
Prophylaxis - child |
454 |
446 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
824 |
810 |
$12K |
| D1110 |
Prophylaxis - adult |
297 |
291 |
$11K |
| D1351 |
Sealant - per tooth |
393 |
98 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
60 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
45 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
287 |
280 |
$4K |
| D0272 |
Bitewings - two radiographic images |
133 |
132 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
235 |
225 |
$3K |