| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,586 |
224 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
172 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,015 |
973 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
511 |
482 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
639 |
606 |
$15K |
| D1110 |
Prophylaxis - adult |
493 |
468 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
108 |
64 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
730 |
697 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
310 |
296 |
$7K |
| D1120 |
Prophylaxis - child |
352 |
337 |
$7K |
| D0350 |
|
329 |
320 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
430 |
405 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
29 |
13 |
$3K |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
38 |
$273.84 |