| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
555 |
522 |
$30K |
| D1120 |
Prophylaxis - child |
683 |
626 |
$26K |
| D1351 |
Sealant - per tooth |
1,020 |
170 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
724 |
661 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
359 |
153 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
414 |
147 |
$14K |
| D1206 |
Topical application of fluoride varnish |
378 |
326 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
360 |
311 |
$10K |
| D0274 |
Bitewings - four radiographic images |
506 |
434 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,790 |
620 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
435 |
384 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
748 |
646 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
237 |
75 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
338 |
307 |
$3K |
| D4346 |
|
86 |
59 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
30 |
$989.76 |
| D0350 |
|
53 |
43 |
$348.50 |