| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
508 |
505 |
$18K |
| D0274 |
Bitewings - four radiographic images |
585 |
581 |
$16K |
| D1351 |
Sealant - per tooth |
591 |
109 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
673 |
670 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
198 |
99 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
358 |
353 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
75 |
$8K |
| D1120 |
Prophylaxis - child |
236 |
236 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
139 |
137 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
701 |
586 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
643 |
634 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
200 |
200 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
26 |
$2K |
| D1206 |
Topical application of fluoride varnish |
124 |
123 |
$2K |
| D0272 |
Bitewings - two radiographic images |
78 |
78 |
$1K |
| D1999 |
|
648 |
616 |
$0.00 |