| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,148 |
201 |
$29K |
| D1110 |
Prophylaxis - adult |
712 |
694 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
374 |
158 |
$25K |
| D0274 |
Bitewings - four radiographic images |
748 |
728 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
869 |
842 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
134 |
$14K |
| D1120 |
Prophylaxis - child |
474 |
458 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
556 |
541 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
257 |
249 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
482 |
482 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
985 |
758 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
877 |
850 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
33 |
$3K |
| D0272 |
Bitewings - two radiographic images |
153 |
153 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
27 |
$2K |
| D1206 |
Topical application of fluoride varnish |
117 |
93 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$1K |
| D1999 |
|
1,175 |
1,038 |
$0.00 |