| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,658 |
241 |
$42K |
| D1110 |
Prophylaxis - adult |
828 |
828 |
$30K |
| D0330 |
Panoramic radiographic image |
730 |
729 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
481 |
271 |
$25K |
| D0274 |
Bitewings - four radiographic images |
893 |
893 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
387 |
256 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
857 |
856 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
652 |
651 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
188 |
116 |
$12K |
| D1206 |
Topical application of fluoride varnish |
613 |
612 |
$11K |
| D1310 |
|
991 |
989 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
198 |
196 |
$11K |
| D1330 |
|
963 |
961 |
$11K |
| D1120 |
Prophylaxis - child |
311 |
310 |
$9K |
| D0272 |
Bitewings - two radiographic images |
248 |
247 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
428 |
424 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
24 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
97 |
$872.96 |