| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
629 |
575 |
$11K |
| D1354 |
|
3,844 |
547 |
$10K |
| D1206 |
Topical application of fluoride varnish |
1,295 |
1,138 |
$5K |
| D0330 |
Panoramic radiographic image |
180 |
171 |
$3K |
| D0274 |
Bitewings - four radiographic images |
160 |
151 |
$1K |
| D1351 |
Sealant - per tooth |
417 |
105 |
$936.40 |
| D1110 |
Prophylaxis - adult |
84 |
82 |
$813.59 |
| D0191 |
|
1,146 |
1,010 |
$640.94 |
| D0140 |
Limited oral evaluation - problem focused |
266 |
228 |
$451.21 |
| D0230 |
Intraoral - periapical each additional radiographic image |
154 |
145 |
$450.01 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
68 |
$430.03 |
| D0120 |
Periodic oral evaluation - established patient |
109 |
102 |
$131.39 |
| D1330 |
|
774 |
702 |
$62.80 |
| D0602 |
|
1,017 |
832 |
$10.00 |
| D0220 |
Intraoral - periapical first radiographic image |
365 |
328 |
$5.98 |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
15 |
$0.00 |
| D0603 |
|
581 |
456 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$0.00 |
| D1355 |
|
54 |
15 |
$0.00 |