| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,919 |
2,714 |
$114K |
| D1206 |
Topical application of fluoride varnish |
2,896 |
2,694 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,174 |
2,014 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
625 |
466 |
$39K |
| D1351 |
Sealant - per tooth |
453 |
246 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,068 |
967 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,099 |
1,009 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
338 |
262 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
2,133 |
1,967 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,909 |
1,744 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
489 |
447 |
$8K |
| D0272 |
Bitewings - two radiographic images |
609 |
574 |
$6K |
| D4341 |
|
20 |
12 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
59 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
24 |
$2K |
| D0330 |
Panoramic radiographic image |
59 |
51 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
60 |
$992.10 |
| D1110 |
Prophylaxis - adult |
17 |
12 |
$492.00 |
| D9310 |
|
12 |
12 |
$188.10 |
| D0270 |
|
12 |
12 |
$67.20 |
| D1999 |
|
893 |
740 |
$0.00 |