| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
776 |
108 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
383 |
362 |
$12K |
| D1120 |
Prophylaxis - child |
293 |
258 |
$11K |
| D1206 |
Topical application of fluoride varnish |
352 |
308 |
$10K |
| D0274 |
Bitewings - four radiographic images |
437 |
394 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
152 |
137 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
161 |
51 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
652 |
598 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
356 |
313 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
43 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
109 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
501 |
441 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
65 |
27 |
$2K |
| D4346 |
|
47 |
27 |
$1K |
| D0270 |
|
41 |
40 |
$424.44 |
| D1110 |
Prophylaxis - adult |
16 |
14 |
$350.00 |