| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
715 |
671 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
111 |
$18K |
| D0274 |
Bitewings - four radiographic images |
499 |
474 |
$17K |
| D1110 |
Prophylaxis - adult |
218 |
211 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
980 |
613 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
729 |
657 |
$10K |
| D0330 |
Panoramic radiographic image |
119 |
116 |
$7K |
| D1351 |
Sealant - per tooth |
214 |
27 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
39 |
$5K |
| D4341 |
|
33 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
88 |
85 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
52 |
50 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
25 |
$947.10 |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
39 |
$767.50 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$509.74 |