| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
919 |
909 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,557 |
1,528 |
$36K |
| D1110 |
Prophylaxis - adult |
442 |
437 |
$12K |
| D1206 |
Topical application of fluoride varnish |
501 |
501 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
349 |
340 |
$8K |
| D0330 |
Panoramic radiographic image |
195 |
194 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
167 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
37 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
42 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$77.30 |