| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,246 |
216 |
$31K |
| D1110 |
Prophylaxis - adult |
564 |
564 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
701 |
700 |
$18K |
| D0274 |
Bitewings - four radiographic images |
599 |
598 |
$16K |
| D1120 |
Prophylaxis - child |
361 |
361 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
348 |
347 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
107 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
241 |
241 |
$4K |
| D1206 |
Topical application of fluoride varnish |
231 |
231 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
485 |
481 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
77 |
77 |
$3K |
| D0272 |
Bitewings - two radiographic images |
172 |
172 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
353 |
311 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$294.64 |
| D1999 |
|
376 |
360 |
$0.00 |