| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
281 |
85 |
$12K |
| D0330 |
Panoramic radiographic image |
126 |
126 |
$11K |
| D1120 |
Prophylaxis - child |
265 |
264 |
$10K |
| D1206 |
Topical application of fluoride varnish |
309 |
308 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
257 |
257 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
50 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
137 |
137 |
$6K |
| D1110 |
Prophylaxis - adult |
85 |
85 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
33 |
$4K |
| D0274 |
Bitewings - four radiographic images |
68 |
68 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
45 |
$2K |
| D1354 |
|
38 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$707.52 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
55 |
$379.65 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
30 |
$224.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$147.67 |