| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,318 |
3,318 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
3,164 |
3,164 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
952 |
425 |
$52K |
| D1351 |
Sealant - per tooth |
830 |
419 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,558 |
1,558 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,156 |
2,156 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,514 |
1,513 |
$20K |
| D1110 |
Prophylaxis - adult |
233 |
233 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
448 |
448 |
$10K |
| D0330 |
Panoramic radiographic image |
286 |
286 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
52 |
$7K |
| D2330 |
|
30 |
15 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
14 |
$711.52 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$163.51 |
| D3120 |
|
23 |
13 |
$0.00 |
| D1999 |
|
241 |
241 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
64 |
58 |
$0.00 |