| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,289 |
1,215 |
$58K |
| D1206 |
Topical application of fluoride varnish |
1,228 |
1,161 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
991 |
957 |
$32K |
| D0274 |
Bitewings - four radiographic images |
265 |
261 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
89 |
$5K |
| D0330 |
Panoramic radiographic image |
155 |
152 |
$4K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$4K |
| D1351 |
Sealant - per tooth |
72 |
26 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
45 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
139 |
131 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$2K |
| D2940 |
|
136 |
41 |
$1K |
| D0272 |
Bitewings - two radiographic images |
106 |
106 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
12 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$754.65 |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
66 |
$476.84 |