| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
530 |
105 |
$13K |
| D1120 |
Prophylaxis - child |
155 |
155 |
$5K |
| D1206 |
Topical application of fluoride varnish |
191 |
191 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
36 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
122 |
$2K |
| D0272 |
Bitewings - two radiographic images |
72 |
72 |
$1K |
| D0274 |
Bitewings - four radiographic images |
34 |
34 |
$952.00 |
| D0120 |
Periodic oral evaluation - established patient |
34 |
34 |
$680.00 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$504.00 |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$416.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
49 |
$384.00 |