| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
530 |
507 |
$34K |
| D1351 |
Sealant - per tooth |
831 |
238 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
219 |
124 |
$27K |
| D0330 |
Panoramic radiographic image |
306 |
291 |
$25K |
| D1120 |
Prophylaxis - child |
502 |
481 |
$25K |
| D1206 |
Topical application of fluoride varnish |
782 |
752 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
151 |
100 |
$23K |
| D0274 |
Bitewings - four radiographic images |
286 |
278 |
$14K |
| D1110 |
Prophylaxis - adult |
177 |
168 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
284 |
274 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
415 |
398 |
$9K |
| D0272 |
Bitewings - two radiographic images |
247 |
241 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
236 |
168 |
$7K |
| D1353 |
|
158 |
57 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
62 |
$2K |