| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,485 |
392 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
504 |
496 |
$18K |
| D1120 |
Prophylaxis - child |
488 |
480 |
$10K |
| D1206 |
Topical application of fluoride varnish |
519 |
510 |
$7K |
| D0272 |
Bitewings - two radiographic images |
260 |
258 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
459 |
362 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
391 |
387 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
73 |
72 |
$2K |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$2K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$423.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$69.00 |