| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
501 |
158 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
284 |
284 |
$19K |
| D1206 |
Topical application of fluoride varnish |
523 |
506 |
$19K |
| D1120 |
Prophylaxis - child |
238 |
238 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
454 |
408 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
498 |
491 |
$10K |
| D0272 |
Bitewings - two radiographic images |
187 |
187 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
158 |
143 |
$6K |
| D0274 |
Bitewings - four radiographic images |
94 |
92 |
$4K |
| D1110 |
Prophylaxis - adult |
62 |
61 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
14 |
$3K |
| D9996 |
|
135 |
135 |
$2K |