| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
301 |
271 |
$15K |
| D1120 |
Prophylaxis - child |
359 |
321 |
$14K |
| D1351 |
Sealant - per tooth |
576 |
78 |
$12K |
| D0274 |
Bitewings - four radiographic images |
358 |
322 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
414 |
361 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
244 |
216 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,006 |
376 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
44 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
139 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
433 |
389 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
41 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
24 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
238 |
207 |
$2K |
| D1206 |
Topical application of fluoride varnish |
37 |
37 |
$1K |