| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,324 |
1,295 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,609 |
948 |
$67K |
| D0330 |
Panoramic radiographic image |
871 |
843 |
$60K |
| D1110 |
Prophylaxis - adult |
934 |
900 |
$59K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
408 |
278 |
$54K |
| D7140 |
Extraction, erupted tooth or exposed root |
642 |
191 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
496 |
306 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
635 |
606 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
96 |
48 |
$17K |
| D0274 |
Bitewings - four radiographic images |
2,207 |
2,146 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
756 |
717 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
2,060 |
2,007 |
$4K |
| D9248 |
|
46 |
44 |
$2K |
| D9996 |
|
25 |
22 |
$1K |
| D1330 |
|
1,752 |
1,714 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
287 |
264 |
$560.08 |
| D0272 |
Bitewings - two radiographic images |
170 |
163 |
$382.06 |
| D1206 |
Topical application of fluoride varnish |
786 |
751 |
$234.13 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,257 |
1,230 |
$149.40 |
| D9987 |
|
214 |
207 |
$0.00 |
| D9986 |
|
664 |
638 |
$0.00 |