| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,907 |
364 |
$47K |
| D1110 |
Prophylaxis - adult |
931 |
930 |
$31K |
| D0274 |
Bitewings - four radiographic images |
857 |
855 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,070 |
1,070 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
338 |
200 |
$19K |
| D1120 |
Prophylaxis - child |
544 |
542 |
$14K |
| D1206 |
Topical application of fluoride varnish |
657 |
654 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
220 |
123 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
392 |
390 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
500 |
492 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
72 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
41 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
385 |
287 |
$3K |
| D0272 |
Bitewings - two radiographic images |
163 |
160 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
101 |
101 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
27 |
$539.80 |
| D1999 |
|
32 |
32 |
$0.00 |