| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
291 |
176 |
$30K |
| D1120 |
Prophylaxis - child |
346 |
346 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
324 |
324 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
315 |
315 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
42 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
53 |
$4K |
| D0274 |
Bitewings - four radiographic images |
116 |
116 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
174 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
151 |
151 |
$667.52 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$426.24 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$321.61 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$229.44 |