| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,398 |
440 |
$27K |
| D1120 |
Prophylaxis - child |
1,094 |
1,078 |
$21K |
| D1354 |
|
1,268 |
451 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
887 |
869 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
573 |
559 |
$15K |
| D1206 |
Topical application of fluoride varnish |
993 |
984 |
$15K |
| D1110 |
Prophylaxis - adult |
282 |
266 |
$9K |
| D0272 |
Bitewings - two radiographic images |
687 |
682 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
105 |
93 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
229 |
210 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
383 |
281 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
339 |
335 |
$2K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$553.00 |