| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,739 |
367 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,971 |
1,932 |
$34K |
| D1120 |
Prophylaxis - child |
1,310 |
1,281 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,925 |
1,894 |
$30K |
| D0274 |
Bitewings - four radiographic images |
895 |
878 |
$20K |
| D1110 |
Prophylaxis - adult |
633 |
626 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
682 |
659 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
726 |
516 |
$5K |
| D0330 |
Panoramic radiographic image |
101 |
101 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
38 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$320.24 |