| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,498 |
1,407 |
$39K |
| D0330 |
Panoramic radiographic image |
601 |
558 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
852 |
818 |
$22K |
| D0274 |
Bitewings - four radiographic images |
831 |
767 |
$20K |
| D1206 |
Topical application of fluoride varnish |
940 |
893 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
544 |
486 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
480 |
434 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
86 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
776 |
648 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
64 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
25 |
$4K |
| D1351 |
Sealant - per tooth |
111 |
17 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
110 |
107 |
$2K |
| D0272 |
Bitewings - two radiographic images |
68 |
62 |
$856.58 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$795.84 |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
44 |
$492.78 |
| D0602 |
|
40 |
40 |
$0.00 |
| D1110 |
Prophylaxis - adult |
15 |
14 |
$0.00 |
| D1999 |
|
18 |
18 |
$0.00 |