| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
647 |
202 |
$11K |
| D1120 |
Prophylaxis - child |
515 |
495 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
367 |
353 |
$8K |
| D1206 |
Topical application of fluoride varnish |
534 |
519 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
133 |
$5K |
| D0272 |
Bitewings - two radiographic images |
324 |
309 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
210 |
146 |
$2K |
| D0274 |
Bitewings - four radiographic images |
89 |
89 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
151 |
147 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$821.00 |