| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,244 |
294 |
$48K |
| D1120 |
Prophylaxis - child |
653 |
624 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,047 |
998 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
841 |
811 |
$17K |
| D1110 |
Prophylaxis - adult |
334 |
316 |
$12K |
| D0272 |
Bitewings - two radiographic images |
236 |
231 |
$5K |
| D0274 |
Bitewings - four radiographic images |
114 |
110 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$840.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
13 |
$368.00 |