| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
4,239 |
4,215 |
$117K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,249 |
681 |
$114K |
| D1120 |
Prophylaxis - child |
2,923 |
2,908 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,345 |
2,330 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
2,070 |
2,060 |
$78K |
| D1330 |
|
2,578 |
2,563 |
$78K |
| D1110 |
Prophylaxis - adult |
1,320 |
1,313 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
835 |
470 |
$60K |
| D0274 |
Bitewings - four radiographic images |
1,269 |
1,263 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
2,804 |
2,769 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,574 |
2,342 |
$35K |
| D1351 |
Sealant - per tooth |
920 |
229 |
$32K |
| D1354 |
|
999 |
247 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
243 |
67 |
$26K |
| D0272 |
Bitewings - two radiographic images |
634 |
633 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
365 |
364 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
106 |
84 |
$12K |
| D4341 |
|
56 |
26 |
$10K |
| D7111 |
|
35 |
25 |
$4K |
| D2331 |
|
18 |
13 |
$2K |
| D2330 |
|
16 |
14 |
$1K |
| D4910 |
|
12 |
12 |
$955.50 |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
17 |
$920.59 |
| D1310 |
|
32 |
32 |
$0.00 |