| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,151 |
646 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
246 |
245 |
$6K |
| D1120 |
Prophylaxis - child |
294 |
294 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
332 |
332 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
320 |
320 |
$5K |
| D1110 |
Prophylaxis - adult |
148 |
148 |
$5K |
| D0274 |
Bitewings - four radiographic images |
71 |
71 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
16 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$972.00 |