| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,311 |
255 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
525 |
477 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
379 |
349 |
$7K |
| D1120 |
Prophylaxis - child |
258 |
233 |
$7K |
| D0274 |
Bitewings - four radiographic images |
262 |
232 |
$6K |
| D1110 |
Prophylaxis - adult |
179 |
166 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
332 |
298 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
272 |
241 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
18 |
17 |
$940.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
27 |
$783.00 |