| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,436 |
260 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
647 |
558 |
$32K |
| D1120 |
Prophylaxis - child |
785 |
686 |
$24K |
| D0272 |
Bitewings - two radiographic images |
703 |
610 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
791 |
688 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
528 |
515 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
782 |
665 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
29 |
$6K |
| D1206 |
Topical application of fluoride varnish |
307 |
221 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
15 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
26 |
26 |
$869.21 |