| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
580 |
135 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
450 |
331 |
$12K |
| D1120 |
Prophylaxis - child |
631 |
475 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
384 |
292 |
$10K |
| D1206 |
Topical application of fluoride varnish |
360 |
284 |
$6K |
| D0272 |
Bitewings - two radiographic images |
216 |
182 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
114 |
94 |
$1K |
| D0350 |
|
52 |
50 |
$1K |
| D0274 |
Bitewings - four radiographic images |
17 |
13 |
$385.72 |
| D0120 |
Periodic oral evaluation - established patient |
18 |
15 |
$365.80 |