| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,232 |
1,199 |
$82K |
| D7140 |
Extraction, erupted tooth or exposed root |
720 |
469 |
$45K |
| D0330 |
Panoramic radiographic image |
694 |
659 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
738 |
729 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
368 |
275 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
333 |
325 |
$15K |
| D0274 |
Bitewings - four radiographic images |
670 |
649 |
$13K |
| D1110 |
Prophylaxis - adult |
186 |
184 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
333 |
315 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
182 |
178 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
78 |
$2K |
| D2331 |
|
14 |
12 |
$391.41 |
| D1206 |
Topical application of fluoride varnish |
560 |
550 |
$339.39 |
| D1351 |
Sealant - per tooth |
37 |
12 |
$251.38 |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
47 |
41 |
$0.00 |