| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
5,557 |
5,391 |
$852K |
| 87428 |
|
1,976 |
1,824 |
$113K |
| D1120 |
Prophylaxis - child |
634 |
611 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
638 |
619 |
$48K |
| D1110 |
Prophylaxis - adult |
258 |
254 |
$45K |
| D0330 |
Panoramic radiographic image |
240 |
234 |
$43K |
| 87426 |
Infectious agent antigen detection, SARS-CoV-2 (COVID-19) |
1,145 |
1,023 |
$29K |
| D0274 |
Bitewings - four radiographic images |
385 |
380 |
$13K |
| 87880 |
Infectious agent antigen detection by immunoassay; Streptococcus, group A |
1,455 |
1,365 |
$11K |
| 87807 |
|
547 |
515 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
27 |
$6K |
| 99238 |
Hospital discharge day management, 30 minutes or less |
119 |
113 |
$5K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
164 |
146 |
$4K |
| 87804 |
Infectious agent antigen detection by immunoassay; Influenza, each type |
156 |
151 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
258 |
253 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| 99204 |
Office or other outpatient visit for the evaluation and management of a new patient, moderate complexity |
13 |
13 |
$428.48 |
| 83036 |
Hemoglobin; glycosylated (A1C) |
14 |
14 |
$70.42 |
| 81025 |
|
12 |
12 |
$66.87 |
| 81003 |
|
110 |
68 |
$39.00 |
| D0190 |
|
1,442 |
1,419 |
$0.00 |