| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
894 |
127 |
$15K |
| D1120 |
Prophylaxis - child |
331 |
325 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
367 |
103 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
267 |
260 |
$8K |
| D0274 |
Bitewings - four radiographic images |
220 |
215 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
83 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
392 |
381 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
398 |
357 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
106 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
309 |
300 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
50 |
22 |
$2K |
| D0330 |
Panoramic radiographic image |
53 |
52 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
77 |
$1K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$527.67 |
| D0270 |
|
24 |
22 |
$259.38 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$234.00 |