| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
5,077 |
5,007 |
$88K |
| D1351 |
Sealant - per tooth |
1,709 |
530 |
$40K |
| D0191 |
|
2,587 |
2,556 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
283 |
277 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
521 |
504 |
$13K |
| D1110 |
Prophylaxis - adult |
361 |
357 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
149 |
102 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
328 |
323 |
$6K |
| D1120 |
Prophylaxis - child |
149 |
149 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
61 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$570.42 |