| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
1,234 |
1,060 |
$351K |
| D1351 |
Sealant - per tooth |
466 |
131 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$264.25 |
| D1120 |
Prophylaxis - child |
28 |
28 |
$160.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$114.00 |
| D0140 |
Limited oral evaluation - problem focused |
74 |
72 |
$110.00 |
| D0120 |
Periodic oral evaluation - established patient |
37 |
37 |
$64.00 |
| D0220 |
Intraoral - periapical first radiographic image |
102 |
101 |
$52.00 |
| D1206 |
Topical application of fluoride varnish |
360 |
359 |
$19.00 |
| D1353 |
|
56 |
34 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
53 |
37 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$0.00 |
| D0190 |
|
210 |
210 |
$0.00 |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$0.00 |
| D0270 |
|
12 |
12 |
$0.00 |