| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,387 |
718 |
$100K |
| D1120 |
Prophylaxis - child |
2,112 |
2,112 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,000 |
690 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,321 |
2,321 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,086 |
2,086 |
$56K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
497 |
368 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
607 |
455 |
$32K |
| D1110 |
Prophylaxis - adult |
598 |
597 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,341 |
1,341 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
899 |
897 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
222 |
146 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
619 |
591 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,523 |
1,484 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
698 |
669 |
$6K |
| D0272 |
Bitewings - two radiographic images |
494 |
494 |
$5K |
| D2332 |
|
31 |
25 |
$3K |
| D2950 |
|
12 |
12 |
$875.42 |
| D1999 |
|
309 |
281 |
$0.00 |