| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,824 |
1,660 |
$19K |
| D1206 |
Topical application of fluoride varnish |
2,568 |
2,353 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
656 |
476 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
1,894 |
1,720 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,461 |
1,237 |
$8K |
| D1110 |
Prophylaxis - adult |
480 |
449 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
147 |
$2K |
| D0272 |
Bitewings - two radiographic images |
1,003 |
926 |
$2K |
| D1330 |
|
2,580 |
2,367 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,749 |
1,577 |
$2K |
| D0274 |
Bitewings - four radiographic images |
631 |
595 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
171 |
$780.76 |
| D0330 |
Panoramic radiographic image |
234 |
233 |
$660.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
193 |
119 |
$575.00 |
| D1351 |
Sealant - per tooth |
289 |
127 |
$76.00 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
24 |
$0.00 |