| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
628 |
237 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
881 |
848 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
236 |
122 |
$16K |
| D1120 |
Prophylaxis - child |
352 |
350 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
402 |
387 |
$9K |
| D1206 |
Topical application of fluoride varnish |
351 |
348 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
242 |
239 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
665 |
652 |
$4K |
| D0330 |
Panoramic radiographic image |
129 |
126 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
294 |
243 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$795.48 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$187.98 |
| D0603 |
|
13 |
13 |
$0.00 |
| D0602 |
|
72 |
70 |
$0.00 |
| D0601 |
|
158 |
156 |
$0.00 |