| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,684 |
1,427 |
$18K |
| D1110 |
Prophylaxis - adult |
518 |
493 |
$14K |
| D1351 |
Sealant - per tooth |
815 |
216 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
814 |
761 |
$12K |
| D1120 |
Prophylaxis - child |
412 |
389 |
$9K |
| D0274 |
Bitewings - four radiographic images |
342 |
321 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
586 |
545 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
71 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
687 |
357 |
$2K |
| D0330 |
Panoramic radiographic image |
102 |
98 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
100 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
12 |
$1K |
| D0191 |
|
335 |
289 |
$965.96 |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
27 |
$854.74 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
13 |
$786.89 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$575.89 |
| D0272 |
Bitewings - two radiographic images |
35 |
34 |
$441.87 |