| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
610 |
213 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
835 |
834 |
$24K |
| D1120 |
Prophylaxis - child |
420 |
420 |
$18K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
134 |
89 |
$17K |
| D4342 |
|
178 |
60 |
$16K |
| D4341 |
|
101 |
41 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
189 |
88 |
$14K |
| D1206 |
Topical application of fluoride varnish |
521 |
519 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
208 |
131 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
93 |
69 |
$9K |
| D0274 |
Bitewings - four radiographic images |
479 |
479 |
$9K |
| D1110 |
Prophylaxis - adult |
200 |
200 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
836 |
831 |
$6K |
| D0330 |
Panoramic radiographic image |
153 |
153 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
790 |
786 |
$4K |
| D2332 |
|
27 |
17 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
43 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
90 |
$2K |
| D0272 |
Bitewings - two radiographic images |
209 |
209 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
88 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$791.70 |