| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,368 |
980 |
$104K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,210 |
479 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,434 |
1,404 |
$64K |
| D1120 |
Prophylaxis - child |
1,204 |
1,180 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,523 |
1,494 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
228 |
136 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,308 |
677 |
$18K |
| D0274 |
Bitewings - four radiographic images |
452 |
444 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
735 |
719 |
$8K |
| D1110 |
Prophylaxis - adult |
169 |
166 |
$5K |
| D0272 |
Bitewings - two radiographic images |
182 |
174 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
104 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
29 |
29 |
$763.00 |