| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
296 |
47 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
388 |
157 |
$4K |
| D0274 |
Bitewings - four radiographic images |
118 |
110 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
206 |
188 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
17 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
97 |
92 |
$2K |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
94 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$1K |
| D1120 |
Prophylaxis - child |
22 |
22 |
$667.80 |
| D1206 |
Topical application of fluoride varnish |
41 |
37 |
$618.96 |