| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,164 |
339 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
494 |
227 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
695 |
279 |
$21K |
| D1110 |
Prophylaxis - adult |
966 |
493 |
$19K |
| D0330 |
Panoramic radiographic image |
556 |
311 |
$18K |
| D0274 |
Bitewings - four radiographic images |
604 |
370 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
1,110 |
562 |
$13K |
| D1206 |
Topical application of fluoride varnish |
1,348 |
701 |
$12K |
| D1120 |
Prophylaxis - child |
523 |
270 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
349 |
175 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
130 |
47 |
$4K |
| D0272 |
Bitewings - two radiographic images |
273 |
151 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
248 |
141 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
13 |
$413.00 |
| D0603 |
|
40 |
38 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
12 |
$0.00 |