| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
694 |
99 |
$20K |
| D1110 |
Prophylaxis - adult |
296 |
292 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
273 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
48 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
146 |
$10K |
| D1206 |
Topical application of fluoride varnish |
335 |
323 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
126 |
126 |
$3K |
| D1120 |
Prophylaxis - child |
70 |
70 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
106 |
$2K |
| D0274 |
Bitewings - four radiographic images |
58 |
58 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$548.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
45 |
$510.70 |
| D0350 |
|
20 |
20 |
$0.00 |
| D1330 |
|
13 |
13 |
$0.00 |