| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
311 |
124 |
$22K |
| D1120 |
Prophylaxis - child |
345 |
345 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
357 |
357 |
$10K |
| D4341 |
|
57 |
26 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
344 |
344 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
260 |
260 |
$6K |
| D0274 |
Bitewings - four radiographic images |
327 |
327 |
$6K |
| D1110 |
Prophylaxis - adult |
105 |
105 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
33 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
48 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
37 |
$3K |
| D2332 |
|
29 |
17 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
426 |
425 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
405 |
378 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
26 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
82 |
$1K |
| D2330 |
|
18 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$133.08 |