| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,360 |
386 |
$52K |
| D1120 |
Prophylaxis - child |
2,142 |
1,799 |
$50K |
| D0330 |
Panoramic radiographic image |
1,034 |
933 |
$40K |
| D1206 |
Topical application of fluoride varnish |
2,050 |
1,724 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
959 |
825 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,075 |
807 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
274 |
128 |
$22K |
| D0274 |
Bitewings - four radiographic images |
983 |
860 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
743 |
704 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
211 |
118 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,619 |
1,167 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
76 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
93 |
88 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
345 |
174 |
$2K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$411.35 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$190.32 |
| D1999 |
|
48 |
42 |
$0.00 |