| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,135 |
2,134 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
2,577 |
2,574 |
$74K |
| D1110 |
Prophylaxis - adult |
661 |
661 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,183 |
1,180 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,296 |
1,295 |
$18K |
| D1354 |
|
1,817 |
355 |
$18K |
| D0330 |
Panoramic radiographic image |
378 |
378 |
$13K |
| D0272 |
Bitewings - two radiographic images |
688 |
688 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
177 |
129 |
$9K |
| D0274 |
Bitewings - four radiographic images |
288 |
288 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
215 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
103 |
55 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
51 |
$5K |
| D1351 |
Sealant - per tooth |
105 |
38 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
230 |
225 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
113 |
$2K |
| D1330 |
|
32 |
32 |
$0.00 |