| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,544 |
842 |
$117K |
| D1206 |
Topical application of fluoride varnish |
6,837 |
6,601 |
$98K |
| H1003 |
Prenatal care, at-risk enhanced service; education |
1,777 |
1,430 |
$66K |
| D1120 |
Prophylaxis - child |
2,516 |
2,457 |
$64K |
| D0191 |
|
4,758 |
4,654 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
2,764 |
2,683 |
$48K |
| D1110 |
Prophylaxis - adult |
1,202 |
1,175 |
$37K |
| T1016 |
Case management, each 15 minutes |
1,598 |
1,446 |
$31K |
| H1004 |
Prenatal care, at-risk enhanced service; follow-up home visit |
822 |
745 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
585 |
343 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
168 |
103 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
130 |
26 |
$17K |
| D0272 |
Bitewings - two radiographic images |
964 |
931 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
280 |
180 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
759 |
729 |
$14K |
| D0274 |
Bitewings - four radiographic images |
712 |
691 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
430 |
407 |
$10K |
| D0330 |
Panoramic radiographic image |
121 |
118 |
$5K |
| D1351 |
Sealant - per tooth |
297 |
94 |
$5K |
| H1010 |
Non-medical family planning education, per session |
94 |
83 |
$4K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
700 |
430 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
532 |
518 |
$4K |
| 83655 |
|
576 |
316 |
$4K |
| T1013 |
Sign language or oral interpretive services, per 15 minutes |
125 |
113 |
$3K |
| 90686 |
|
88 |
77 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
13 |
$1K |
| 36416 |
|
465 |
249 |
$668.01 |
| H1002 |
Prenatal care, at risk enhanced service; care coordination |
13 |
13 |
$634.27 |
| H1000 |
Prenatal care, at-risk assessment |
13 |
13 |
$525.20 |
| 87591 |
Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, amplified probe |
20 |
17 |
$490.00 |
| 87491 |
Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe |
20 |
17 |
$490.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
73 |
$434.14 |
| D0240 |
|
24 |
14 |
$220.50 |
| S4993 |
Contraceptive pills for birth control |
31 |
27 |
$139.77 |
| A4267 |
Contraceptive supply, condom, male, each |
44 |
39 |
$128.18 |
| 99000 |
|
42 |
37 |
$123.60 |
| A4268 |
Contraceptive supply, condom, female, each |
16 |
14 |
$36.00 |