| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
465 |
91 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
357 |
356 |
$10K |
| D1110 |
Prophylaxis - adult |
138 |
138 |
$7K |
| D1120 |
Prophylaxis - child |
176 |
175 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
47 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
32 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
340 |
339 |
$5K |
| D0274 |
Bitewings - four radiographic images |
134 |
134 |
$4K |
| D0272 |
Bitewings - two radiographic images |
108 |
108 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$353.20 |
| D0603 |
|
431 |
423 |
$0.00 |