| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
360 |
208 |
$32K |
| D1120 |
Prophylaxis - child |
727 |
726 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
753 |
752 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
722 |
721 |
$20K |
| D0274 |
Bitewings - four radiographic images |
495 |
494 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
74 |
$7K |
| D1110 |
Prophylaxis - adult |
119 |
119 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
656 |
655 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
734 |
728 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
182 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$876.11 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$535.36 |