| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
578 |
577 |
$38K |
| D1351 |
Sealant - per tooth |
906 |
196 |
$29K |
| D1120 |
Prophylaxis - child |
505 |
498 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
189 |
188 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,567 |
485 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
237 |
237 |
$11K |
| D0340 |
|
205 |
205 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
74 |
$9K |
| D0274 |
Bitewings - four radiographic images |
245 |
243 |
$5K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
289 |
283 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
29 |
$3K |
| D1206 |
Topical application of fluoride varnish |
205 |
204 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
21 |
$3K |
| D0330 |
Panoramic radiographic image |
139 |
139 |
$1K |
| D0350 |
|
195 |
49 |
$1K |