| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,522 |
260 |
$39K |
| D1110 |
Prophylaxis - adult |
632 |
629 |
$21K |
| D0274 |
Bitewings - four radiographic images |
710 |
707 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
531 |
530 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
469 |
467 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
419 |
419 |
$7K |
| D1120 |
Prophylaxis - child |
296 |
296 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
545 |
540 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
462 |
419 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
28 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
45 |
$866.72 |
| D0272 |
Bitewings - two radiographic images |
51 |
51 |
$788.96 |