| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
415 |
379 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,823 |
469 |
$9K |
| D1206 |
Topical application of fluoride varnish |
219 |
182 |
$8K |
| D0274 |
Bitewings - four radiographic images |
419 |
352 |
$8K |
| D1351 |
Sealant - per tooth |
410 |
61 |
$7K |
| D5110 |
|
17 |
13 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
534 |
451 |
$6K |
| D0330 |
Panoramic radiographic image |
193 |
176 |
$6K |
| D1120 |
Prophylaxis - child |
133 |
115 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
178 |
71 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
76 |
70 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
199 |
164 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
119 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
38 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
12 |
$1K |
| D4346 |
|
43 |
29 |
$636.00 |
| D5899 |
|
63 |
34 |
$553.50 |