| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
710 |
242 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
191 |
149 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
532 |
531 |
$10K |
| D1120 |
Prophylaxis - child |
588 |
587 |
$10K |
| D1206 |
Topical application of fluoride varnish |
683 |
682 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
159 |
$5K |
| D0272 |
Bitewings - two radiographic images |
395 |
394 |
$4K |
| D0274 |
Bitewings - four radiographic images |
230 |
230 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
269 |
170 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
191 |
191 |
$2K |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$880.00 |