| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,381 |
228 |
$47K |
| D1120 |
Prophylaxis - child |
619 |
610 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
457 |
452 |
$24K |
| D1206 |
Topical application of fluoride varnish |
767 |
766 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
332 |
319 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
28 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
316 |
308 |
$7K |
| D1110 |
Prophylaxis - adult |
97 |
96 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
154 |
152 |
$5K |
| D1330 |
|
665 |
657 |
$4K |
| D0274 |
Bitewings - four radiographic images |
59 |
58 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
45 |
$587.92 |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
60 |
$564.30 |