| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
892 |
120 |
$23K |
| D0330 |
Panoramic radiographic image |
605 |
603 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
372 |
199 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
741 |
739 |
$15K |
| D1110 |
Prophylaxis - adult |
380 |
380 |
$14K |
| D0274 |
Bitewings - four radiographic images |
484 |
483 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
161 |
107 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
171 |
120 |
$9K |
| D1206 |
Topical application of fluoride varnish |
365 |
365 |
$7K |
| D1120 |
Prophylaxis - child |
214 |
214 |
$7K |
| D5110 |
|
13 |
13 |
$5K |
| D1330 |
|
292 |
292 |
$3K |
| D1310 |
|
294 |
294 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
33 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
135 |
135 |
$3K |
| D0272 |
Bitewings - two radiographic images |
143 |
143 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
283 |
280 |
$1K |
| D9110 |
|
30 |
29 |
$845.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
95 |
93 |
$578.82 |