| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,494 |
247 |
$38K |
| D1110 |
Prophylaxis - adult |
626 |
625 |
$22K |
| D0274 |
Bitewings - four radiographic images |
849 |
847 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
334 |
139 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
669 |
667 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
635 |
635 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
262 |
262 |
$11K |
| D1120 |
Prophylaxis - child |
369 |
369 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
80 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
489 |
489 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,007 |
768 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
845 |
841 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
48 |
48 |
$1K |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$527.40 |
| D1999 |
|
393 |
368 |
$0.00 |