| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,079 |
236 |
$23K |
| D1120 |
Prophylaxis - child |
555 |
500 |
$22K |
| D1206 |
Topical application of fluoride varnish |
550 |
492 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
216 |
194 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
304 |
278 |
$9K |
| D0274 |
Bitewings - four radiographic images |
423 |
375 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
290 |
248 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
66 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
41 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
650 |
422 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
256 |
215 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$332.40 |