| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,429 |
2,344 |
$97K |
| D1110 |
Prophylaxis - adult |
1,587 |
1,558 |
$87K |
| D1206 |
Topical application of fluoride varnish |
3,718 |
3,593 |
$75K |
| D0330 |
Panoramic radiographic image |
1,181 |
1,122 |
$69K |
| D0140 |
Limited oral evaluation - problem focused |
1,790 |
1,162 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,472 |
2,383 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
591 |
318 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
355 |
260 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
247 |
127 |
$21K |
| D0272 |
Bitewings - two radiographic images |
447 |
435 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
336 |
319 |
$11K |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$1K |
| D0350 |
|
30 |
28 |
$480.00 |