| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,362 |
438 |
$65K |
| D1120 |
Prophylaxis - child |
749 |
749 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,055 |
1,055 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
172 |
117 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
220 |
149 |
$20K |
| D1110 |
Prophylaxis - adult |
388 |
388 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
613 |
613 |
$14K |
| D1206 |
Topical application of fluoride varnish |
429 |
429 |
$12K |
| D0274 |
Bitewings - four radiographic images |
220 |
220 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
222 |
217 |
$4K |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$964.52 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
27 |
$315.00 |