| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,402 |
144 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
123 |
123 |
$9K |
| D4355 |
|
88 |
88 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
138 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
125 |
125 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
14 |
$4K |
| D1110 |
Prophylaxis - adult |
75 |
74 |
$4K |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$423.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$297.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$223.16 |