| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,096 |
146 |
$27K |
| D0274 |
Bitewings - four radiographic images |
491 |
488 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
482 |
479 |
$12K |
| D1110 |
Prophylaxis - adult |
338 |
332 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
175 |
61 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
321 |
316 |
$7K |
| D1120 |
Prophylaxis - child |
204 |
203 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
135 |
134 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
781 |
523 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
308 |
304 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
542 |
541 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
58 |
58 |
$931.20 |
| D1999 |
|
278 |
266 |
$34.00 |