| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
368 |
60 |
$9K |
| D1110 |
Prophylaxis - adult |
190 |
189 |
$7K |
| D0274 |
Bitewings - four radiographic images |
239 |
237 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
227 |
225 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
150 |
$4K |
| D1120 |
Prophylaxis - child |
127 |
127 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
171 |
171 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
158 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
128 |
120 |
$975.20 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$969.50 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$782.06 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$585.00 |
| D1999 |
|
131 |
128 |
$0.00 |