| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
936 |
237 |
$23K |
| D1120 |
Prophylaxis - child |
486 |
486 |
$15K |
| D1206 |
Topical application of fluoride varnish |
580 |
578 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
353 |
353 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
46 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
270 |
269 |
$6K |
| D0272 |
Bitewings - two radiographic images |
306 |
306 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
245 |
210 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
234 |
233 |
$2K |
| D1354 |
|
213 |
65 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$1K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$972.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
15 |
$800.00 |
| D1310 |
|
13 |
13 |
$146.00 |