| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
236 |
57 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
114 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
18 |
$2K |
| D1120 |
Prophylaxis - child |
71 |
67 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
32 |
$2K |
| D1110 |
Prophylaxis - adult |
45 |
42 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
132 |
123 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
109 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
110 |
93 |
$1K |
| D0272 |
Bitewings - two radiographic images |
47 |
44 |
$1K |
| D0603 |
|
200 |
188 |
$0.00 |