| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,915 |
702 |
$178K |
| D1120 |
Prophylaxis - child |
729 |
729 |
$29K |
| D0191 |
|
962 |
960 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
889 |
888 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
27 |
$14K |
| D0274 |
Bitewings - four radiographic images |
355 |
355 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
544 |
544 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
655 |
542 |
$7K |
| D1110 |
Prophylaxis - adult |
116 |
115 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
146 |
146 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
14 |
$5K |
| D0272 |
Bitewings - two radiographic images |
78 |
78 |
$2K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$300.00 |