| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
765 |
245 |
$38K |
| D1206 |
Topical application of fluoride varnish |
782 |
776 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
86 |
$25K |
| D1120 |
Prophylaxis - child |
337 |
334 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
201 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
47 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
292 |
237 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
324 |
319 |
$8K |
| D0272 |
Bitewings - two radiographic images |
84 |
82 |
$3K |
| D1110 |
Prophylaxis - adult |
42 |
40 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
34 |
34 |
$2K |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$929.00 |
| D9996 |
|
12 |
12 |
$142.00 |