| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
791 |
130 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
242 |
103 |
$13K |
| D1110 |
Prophylaxis - adult |
354 |
353 |
$12K |
| D0274 |
Bitewings - four radiographic images |
425 |
423 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
410 |
409 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
170 |
80 |
$8K |
| D1120 |
Prophylaxis - child |
185 |
184 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
277 |
276 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
214 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
352 |
350 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
346 |
266 |
$2K |
| D0272 |
Bitewings - two radiographic images |
61 |
61 |
$930.72 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$573.80 |
| D9920 |
|
13 |
13 |
$0.00 |