| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,696 |
1,692 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,425 |
2,420 |
$64K |
| D1110 |
Prophylaxis - adult |
838 |
837 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,175 |
1,175 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
884 |
882 |
$12K |
| D0330 |
Panoramic radiographic image |
273 |
273 |
$10K |
| D0272 |
Bitewings - two radiographic images |
421 |
421 |
$7K |
| D0274 |
Bitewings - four radiographic images |
185 |
185 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
58 |
$4K |
| D9997 |
|
78 |
78 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
73 |
73 |
$864.75 |
| D0140 |
Limited oral evaluation - problem focused |
45 |
45 |
$612.50 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$342.00 |
| D1999 |
|
123 |
122 |
$0.00 |