| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
308 |
130 |
$20K |
| D1120 |
Prophylaxis - child |
358 |
358 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
384 |
384 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
150 |
115 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
117 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
339 |
339 |
$9K |
| D1110 |
Prophylaxis - adult |
151 |
151 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
253 |
253 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
62 |
$6K |
| D0274 |
Bitewings - four radiographic images |
324 |
324 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
240 |
231 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
661 |
653 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
494 |
494 |
$3K |
| D0272 |
Bitewings - two radiographic images |
101 |
101 |
$1K |
| D0270 |
|
66 |
65 |
$369.60 |