| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,053 |
2,025 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
503 |
498 |
$18K |
| D1351 |
Sealant - per tooth |
738 |
241 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
431 |
420 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
167 |
$14K |
| D1110 |
Prophylaxis - adult |
224 |
220 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
227 |
225 |
$10K |
| D0191 |
|
1,903 |
1,868 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
114 |
53 |
$9K |
| D1120 |
Prophylaxis - child |
250 |
248 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
336 |
334 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
646 |
625 |
$8K |
| D0274 |
Bitewings - four radiographic images |
183 |
182 |
$4K |
| D0330 |
Panoramic radiographic image |
105 |
104 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
33 |
$3K |
| D0270 |
|
191 |
189 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
112 |
44 |
$934.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$216.70 |
| D9995 |
|
12 |
12 |
$6.00 |
| D0460 |
|
16 |
16 |
$0.00 |