| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,490 |
172 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
123 |
$27K |
| D1110 |
Prophylaxis - adult |
368 |
365 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
709 |
702 |
$21K |
| D1206 |
Topical application of fluoride varnish |
772 |
769 |
$19K |
| D1120 |
Prophylaxis - child |
440 |
435 |
$19K |
| D0330 |
Panoramic radiographic image |
177 |
176 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
38 |
$7K |
| D0274 |
Bitewings - four radiographic images |
277 |
276 |
$6K |
| D1330 |
|
215 |
214 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$875.50 |
| D9910 |
|
48 |
43 |
$480.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$225.00 |