| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,407 |
178 |
$35K |
| D9920 |
|
242 |
212 |
$30K |
| D1110 |
Prophylaxis - adult |
508 |
485 |
$18K |
| D0274 |
Bitewings - four radiographic images |
427 |
403 |
$12K |
| D1120 |
Prophylaxis - child |
340 |
339 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
475 |
455 |
$10K |
| D1206 |
Topical application of fluoride varnish |
461 |
437 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
282 |
280 |
$6K |
| D0272 |
Bitewings - two radiographic images |
79 |
79 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$595.44 |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$360.00 |