| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
505 |
205 |
$32K |
| D4341 |
|
170 |
68 |
$22K |
| D1120 |
Prophylaxis - child |
502 |
502 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
687 |
687 |
$20K |
| D4342 |
|
113 |
55 |
$12K |
| D1206 |
Topical application of fluoride varnish |
431 |
431 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
142 |
89 |
$10K |
| D0274 |
Bitewings - four radiographic images |
537 |
537 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
82 |
$9K |
| D1110 |
Prophylaxis - adult |
146 |
146 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
961 |
954 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
226 |
226 |
$6K |
| D0330 |
Panoramic radiographic image |
340 |
340 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
890 |
889 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
53 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
17 |
$2K |
| D0272 |
Bitewings - two radiographic images |
220 |
220 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
121 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
80 |
80 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
16 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$120.81 |