| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,754 |
1,748 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,284 |
2,276 |
$53K |
| D1110 |
Prophylaxis - adult |
1,505 |
1,501 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,593 |
2,584 |
$49K |
| D0251 |
|
2,680 |
2,671 |
$32K |
| D0330 |
Panoramic radiographic image |
887 |
884 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
884 |
884 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
268 |
261 |
$9K |
| D9920 |
|
295 |
287 |
$7K |
| D1206 |
Topical application of fluoride varnish |
128 |
127 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
122 |
122 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$866.25 |
| D0602 |
|
17 |
17 |
$165.00 |
| D0601 |
|
16 |
16 |
$155.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$115.00 |
| D1999 |
|
380 |
378 |
$0.00 |