| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
275 |
226 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
221 |
59 |
$8K |
| D1120 |
Prophylaxis - child |
167 |
134 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
180 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
41 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
84 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
184 |
147 |
$2K |
| D1351 |
Sealant - per tooth |
54 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
139 |
112 |
$1K |
| D0160 |
|
62 |
59 |
$1K |
| D0330 |
Panoramic radiographic image |
27 |
14 |
$536.12 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$385.00 |
| D0274 |
Bitewings - four radiographic images |
30 |
15 |
$329.98 |