| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,702 |
3,596 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
5,370 |
5,220 |
$154K |
| D1110 |
Prophylaxis - adult |
2,015 |
1,956 |
$116K |
| D1351 |
Sealant - per tooth |
2,303 |
342 |
$75K |
| D1206 |
Topical application of fluoride varnish |
2,757 |
2,715 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,839 |
2,718 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
199 |
128 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,012 |
983 |
$22K |
| D0330 |
Panoramic radiographic image |
424 |
418 |
$18K |
| D1330 |
|
2,796 |
2,705 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
145 |
84 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
94 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
74 |
40 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
219 |
212 |
$11K |
| D0272 |
Bitewings - two radiographic images |
392 |
389 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$1K |
| D9110 |
|
12 |
12 |
$240.00 |