| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
614 |
122 |
$15K |
| D1110 |
Prophylaxis - adult |
361 |
361 |
$12K |
| D0274 |
Bitewings - four radiographic images |
397 |
397 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
537 |
537 |
$10K |
| D1120 |
Prophylaxis - child |
261 |
261 |
$6K |
| D1206 |
Topical application of fluoride varnish |
174 |
174 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
154 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
169 |
169 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
37 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
29 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
358 |
356 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
167 |
159 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$612.40 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$517.33 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$470.96 |