| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,939 |
599 |
$96K |
| D1110 |
Prophylaxis - adult |
1,325 |
1,290 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,837 |
1,795 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,596 |
1,559 |
$43K |
| D1120 |
Prophylaxis - child |
911 |
896 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
979 |
959 |
$26K |
| D1206 |
Topical application of fluoride varnish |
916 |
887 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
299 |
293 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,248 |
1,224 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
163 |
106 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,049 |
870 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
385 |
385 |
$7K |
| D0272 |
Bitewings - two radiographic images |
409 |
403 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
105 |
103 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
39 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
25 |
$2K |
| D1999 |
|
1,129 |
1,033 |
$0.00 |