| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
911 |
305 |
$11K |
| D1120 |
Prophylaxis - child |
677 |
669 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
171 |
110 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
299 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
461 |
454 |
$7K |
| D1206 |
Topical application of fluoride varnish |
750 |
742 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
581 |
354 |
$5K |
| D0272 |
Bitewings - two radiographic images |
350 |
345 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
72 |
$3K |
| D0274 |
Bitewings - four radiographic images |
230 |
227 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
385 |
$3K |
| D1110 |
Prophylaxis - adult |
34 |
34 |
$614.00 |