| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,241 |
236 |
$27K |
| D0274 |
Bitewings - four radiographic images |
484 |
446 |
$12K |
| D1120 |
Prophylaxis - child |
478 |
429 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
547 |
501 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
568 |
520 |
$9K |
| D1110 |
Prophylaxis - adult |
236 |
222 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
68 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
29 |
26 |
$480.00 |
| D1206 |
Topical application of fluoride varnish |
33 |
32 |
$476.00 |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
12 |
$144.00 |