| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,581 |
4,787 |
$149K |
| D1206 |
Topical application of fluoride varnish |
4,112 |
3,578 |
$90K |
| D0330 |
Panoramic radiographic image |
1,957 |
1,697 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,430 |
2,227 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,508 |
1,113 |
$45K |
| D0140 |
Limited oral evaluation - problem focused |
890 |
729 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,045 |
863 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
253 |
161 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,265 |
1,049 |
$18K |
| D0272 |
Bitewings - two radiographic images |
602 |
564 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
458 |
371 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
26 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
25 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
13 |
$2K |
| D1999 |
|
148 |
130 |
$0.00 |