| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,553 |
1,518 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
520 |
352 |
$35K |
| D1120 |
Prophylaxis - child |
814 |
813 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,085 |
1,084 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
280 |
182 |
$20K |
| D1351 |
Sealant - per tooth |
628 |
145 |
$17K |
| D1110 |
Prophylaxis - adult |
403 |
403 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
268 |
196 |
$15K |
| D1310 |
|
1,158 |
1,157 |
$12K |
| D1330 |
|
1,123 |
1,122 |
$12K |
| D0274 |
Bitewings - four radiographic images |
347 |
347 |
$10K |
| D0272 |
Bitewings - two radiographic images |
490 |
490 |
$9K |
| D0330 |
Panoramic radiographic image |
165 |
165 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
120 |
118 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
121 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
201 |
199 |
$2K |
| D0240 |
|
55 |
34 |
$901.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
41 |
$399.45 |
| D0603 |
|
17 |
17 |
$170.00 |