| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4346 |
|
182 |
172 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
143 |
70 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
96 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
219 |
205 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
147 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
139 |
$3K |
| D4355 |
|
38 |
36 |
$3K |
| D1120 |
Prophylaxis - child |
103 |
100 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
51 |
30 |
$2K |
| D1206 |
Topical application of fluoride varnish |
80 |
79 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
87 |
78 |
$993.42 |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$728.98 |
| D1351 |
Sealant - per tooth |
31 |
12 |
$411.84 |
| D0272 |
Bitewings - two radiographic images |
33 |
31 |
$411.31 |
| D2140 |
|
14 |
12 |
$398.94 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
27 |
$212.46 |