| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
513 |
115 |
$16K |
| D1120 |
Prophylaxis - child |
269 |
269 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
613 |
290 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
155 |
$6K |
| D1206 |
Topical application of fluoride varnish |
286 |
286 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
290 |
290 |
$4K |
| D0272 |
Bitewings - two radiographic images |
136 |
136 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
100 |
100 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$871.32 |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$794.72 |