| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
7,559 |
7,458 |
$181K |
| D0120 |
Periodic oral evaluation - established patient |
6,779 |
6,777 |
$168K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,766 |
1,165 |
$149K |
| D1110 |
Prophylaxis - adult |
3,455 |
3,455 |
$130K |
| D1120 |
Prophylaxis - child |
3,459 |
3,459 |
$101K |
| D1999 |
|
8,957 |
8,647 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
726 |
531 |
$47K |
| D0274 |
Bitewings - four radiographic images |
2,133 |
2,133 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
708 |
707 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
242 |
180 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
722 |
722 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
160 |
85 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
511 |
505 |
$3K |
| D0330 |
Panoramic radiographic image |
350 |
349 |
$2K |
| D2140 |
|
39 |
25 |
$2K |
| D2394 |
|
15 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
70 |
$2K |
| D1351 |
Sealant - per tooth |
46 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$392.37 |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
39 |
$291.20 |