| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,540 |
2,536 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,621 |
2,619 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,993 |
2,990 |
$35K |
| D1110 |
Prophylaxis - adult |
538 |
538 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
299 |
196 |
$17K |
| D0272 |
Bitewings - two radiographic images |
905 |
905 |
$11K |
| D0330 |
Panoramic radiographic image |
376 |
376 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
373 |
371 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
93 |
$6K |
| D1351 |
Sealant - per tooth |
116 |
53 |
$4K |
| D0240 |
|
177 |
112 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
53 |
39 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
143 |
$1K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$495.07 |
| D0230 |
Intraoral - periapical each additional radiographic image |
80 |
80 |
$415.40 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
24 |
$294.41 |
| D1999 |
|
23 |
23 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
14 |
14 |
$0.00 |