| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
788 |
785 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,028 |
1,023 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
736 |
736 |
$19K |
| D1110 |
Prophylaxis - adult |
291 |
291 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
357 |
356 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
64 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
13 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
175 |
$3K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$2K |
| D0272 |
Bitewings - two radiographic images |
62 |
62 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
12 |
$220.00 |
| D1999 |
|
99 |
95 |
$0.00 |