| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
751 |
113 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
236 |
96 |
$16K |
| D0274 |
Bitewings - four radiographic images |
462 |
461 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
479 |
479 |
$10K |
| D1110 |
Prophylaxis - adult |
279 |
279 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
320 |
319 |
$7K |
| D1120 |
Prophylaxis - child |
239 |
239 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
46 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
46 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
251 |
250 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
661 |
499 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
545 |
543 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
77 |
77 |
$3K |
| D1206 |
Topical application of fluoride varnish |
92 |
92 |
$2K |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$1K |
| D1999 |
|
517 |
492 |
$0.00 |