| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
363 |
62 |
$9K |
| D0330 |
Panoramic radiographic image |
205 |
204 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
55 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
273 |
273 |
$5K |
| D0274 |
Bitewings - four radiographic images |
192 |
192 |
$5K |
| D1110 |
Prophylaxis - adult |
143 |
143 |
$5K |
| D1330 |
|
436 |
436 |
$4K |
| D1310 |
|
415 |
415 |
$4K |
| D9920 |
|
28 |
26 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
166 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
138 |
138 |
$3K |
| D1120 |
Prophylaxis - child |
56 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
262 |
221 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
92 |
$1K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$686.91 |