| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
963 |
143 |
$29K |
| D1120 |
Prophylaxis - child |
483 |
483 |
$20K |
| D1206 |
Topical application of fluoride varnish |
623 |
623 |
$17K |
| D1354 |
|
528 |
138 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
194 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
29 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
216 |
216 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
43 |
$4K |
| D1110 |
Prophylaxis - adult |
48 |
48 |
$3K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
89 |
44 |
$977.98 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
55 |
$957.50 |