| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
313 |
249 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
342 |
225 |
$5K |
| D1120 |
Prophylaxis - child |
85 |
68 |
$2K |
| D1206 |
Topical application of fluoride varnish |
98 |
81 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
73 |
$1K |
| D1351 |
Sealant - per tooth |
63 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
135 |
83 |
$412.40 |
| D0220 |
Intraoral - periapical first radiographic image |
123 |
64 |
$308.00 |
| D5899 |
|
19 |
13 |
$20.50 |
| D9420 |
|
26 |
12 |
$0.00 |
| D4355 |
|
44 |
20 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
185 |
14 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
156 |
15 |
$0.00 |