| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
249 |
134 |
$21K |
| D1120 |
Prophylaxis - child |
395 |
394 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
454 |
452 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
89 |
68 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
379 |
377 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
66 |
$9K |
| D1110 |
Prophylaxis - adult |
154 |
154 |
$7K |
| D0274 |
Bitewings - four radiographic images |
348 |
347 |
$7K |
| D2332 |
|
45 |
27 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
236 |
236 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
44 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
33 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
345 |
339 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
236 |
234 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
92 |
91 |
$2K |
| D0272 |
Bitewings - two radiographic images |
49 |
49 |
$532.32 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$133.08 |