| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
713 |
713 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
242 |
212 |
$37K |
| D0274 |
Bitewings - four radiographic images |
720 |
719 |
$33K |
| D1206 |
Topical application of fluoride varnish |
896 |
894 |
$30K |
| D1120 |
Prophylaxis - child |
612 |
611 |
$26K |
| D1351 |
Sealant - per tooth |
555 |
143 |
$21K |
| D1110 |
Prophylaxis - adult |
340 |
338 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
90 |
$12K |
| D0330 |
Panoramic radiographic image |
149 |
149 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
79 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
113 |
112 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
78 |
$2K |