| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,564 |
376 |
$66K |
| D1206 |
Topical application of fluoride varnish |
1,730 |
1,559 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
578 |
533 |
$23K |
| D1120 |
Prophylaxis - child |
376 |
349 |
$20K |
| D1110 |
Prophylaxis - adult |
124 |
116 |
$10K |
| D0274 |
Bitewings - four radiographic images |
132 |
119 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
16 |
$5K |
| D4910 |
|
62 |
54 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
184 |
169 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
88 |
$2K |
| D0272 |
Bitewings - two radiographic images |
46 |
44 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
24 |
$2K |