| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,981 |
746 |
$117K |
| D4341 |
|
561 |
293 |
$83K |
| D1120 |
Prophylaxis - child |
1,839 |
1,831 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
1,995 |
1,983 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,776 |
1,769 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,793 |
1,784 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,180 |
1,175 |
$29K |
| D1110 |
Prophylaxis - adult |
618 |
614 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
270 |
216 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
2,528 |
2,507 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,485 |
2,246 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
167 |
105 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
426 |
424 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
116 |
$6K |
| D0272 |
Bitewings - two radiographic images |
341 |
341 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$164.13 |
| D1999 |
|
702 |
656 |
$0.00 |