| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
281 |
39 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
83 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
32 |
32 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
55 |
55 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
117 |
44 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
64 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$740.31 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$280.72 |