| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
327 |
90 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
339 |
329 |
$14K |
| D1120 |
Prophylaxis - child |
414 |
413 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
451 |
448 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
283 |
282 |
$7K |
| D1110 |
Prophylaxis - adult |
137 |
136 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
153 |
107 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
238 |
237 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
545 |
536 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
145 |
$4K |
| D0274 |
Bitewings - four radiographic images |
240 |
236 |
$4K |
| D4341 |
|
36 |
20 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
57 |
$3K |
| D1206 |
Topical application of fluoride varnish |
146 |
146 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
364 |
316 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
54 |
$2K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$166.35 |
| D1999 |
|
156 |
148 |
$0.00 |