| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
499 |
215 |
$31K |
| D1120 |
Prophylaxis - child |
551 |
551 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
217 |
111 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
608 |
608 |
$16K |
| D1206 |
Topical application of fluoride varnish |
509 |
509 |
$14K |
| D1110 |
Prophylaxis - adult |
264 |
264 |
$13K |
| D0274 |
Bitewings - four radiographic images |
620 |
620 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
398 |
398 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
112 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
994 |
992 |
$7K |
| D0330 |
Panoramic radiographic image |
369 |
369 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
930 |
930 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
58 |
$3K |
| D0272 |
Bitewings - two radiographic images |
198 |
198 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
74 |
73 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$327.60 |