| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
857 |
143 |
$23K |
| D1110 |
Prophylaxis - adult |
511 |
511 |
$19K |
| D0274 |
Bitewings - four radiographic images |
633 |
632 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
584 |
584 |
$13K |
| D1120 |
Prophylaxis - child |
267 |
267 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
261 |
261 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
786 |
585 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
654 |
651 |
$5K |
| D1206 |
Topical application of fluoride varnish |
183 |
183 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
199 |
199 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
30 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$693.00 |
| D1999 |
|
19 |
19 |
$0.00 |