| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,232 |
3,232 |
$74K |
| D1110 |
Prophylaxis - adult |
1,465 |
1,464 |
$50K |
| D1120 |
Prophylaxis - child |
1,371 |
1,371 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,236 |
1,224 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,121 |
1,044 |
$21K |
| D1999 |
|
1,735 |
1,702 |
$17K |
| D0272 |
Bitewings - two radiographic images |
558 |
558 |
$7K |
| D0274 |
Bitewings - four radiographic images |
233 |
233 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
61 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$210.00 |