| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
158 |
142 |
$3K |
| D1351 |
Sealant - per tooth |
88 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
103 |
78 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
350 |
310 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
269 |
180 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$815.00 |
| D0274 |
Bitewings - four radiographic images |
114 |
100 |
$765.00 |
| D0601 |
|
15 |
15 |
$150.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$112.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$60.00 |