| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
986 |
894 |
$32K |
| D0330 |
Panoramic radiographic image |
731 |
640 |
$32K |
| D1351 |
Sealant - per tooth |
1,490 |
360 |
$23K |
| D1110 |
Prophylaxis - adult |
686 |
591 |
$20K |
| D1354 |
|
2,324 |
372 |
$11K |
| D1206 |
Topical application of fluoride varnish |
1,851 |
1,697 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
129 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
205 |
136 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
615 |
533 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
710 |
635 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
265 |
256 |
$4K |
| D0274 |
Bitewings - four radiographic images |
588 |
558 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
87 |
40 |
$2K |
| D0191 |
|
1,113 |
1,041 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
208 |
195 |
$876.94 |
| D1330 |
|
1,639 |
1,453 |
$148.46 |
| D0602 |
|
2,250 |
1,675 |
$90.00 |
| D0272 |
Bitewings - two radiographic images |
49 |
46 |
$26.76 |
| D0220 |
Intraoral - periapical first radiographic image |
677 |
611 |
$16.02 |
| D0603 |
|
637 |
537 |
$0.00 |
| D1355 |
|
51 |
12 |
$0.00 |
| D0270 |
|
13 |
13 |
$0.00 |