| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,637 |
2,629 |
$107K |
| D1206 |
Topical application of fluoride varnish |
2,728 |
2,720 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,814 |
2,802 |
$64K |
| D0140 |
Limited oral evaluation - problem focused |
1,512 |
1,438 |
$53K |
| D1110 |
Prophylaxis - adult |
754 |
748 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,875 |
1,865 |
$20K |
| D0330 |
Panoramic radiographic image |
661 |
657 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
319 |
233 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
827 |
823 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
192 |
151 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
108 |
67 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
526 |
509 |
$2K |
| D1351 |
Sealant - per tooth |
88 |
25 |
$1K |
| D0602 |
|
26 |
26 |
$180.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
34 |
$84.00 |
| D1330 |
|
530 |
525 |
$0.00 |
| D1999 |
|
233 |
198 |
$0.00 |