| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,745 |
474 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
755 |
747 |
$59K |
| D1206 |
Topical application of fluoride varnish |
1,367 |
1,343 |
$53K |
| D1120 |
Prophylaxis - child |
848 |
837 |
$48K |
| D0330 |
Panoramic radiographic image |
507 |
504 |
$45K |
| D1110 |
Prophylaxis - adult |
434 |
422 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
174 |
98 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
123 |
86 |
$28K |
| D0274 |
Bitewings - four radiographic images |
468 |
461 |
$28K |
| D0272 |
Bitewings - two radiographic images |
743 |
728 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
553 |
540 |
$24K |
| D9996 |
|
18 |
18 |
$227.00 |