| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,537 |
2,273 |
$101K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
950 |
653 |
$85K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,448 |
2,196 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,998 |
1,770 |
$54K |
| D1351 |
Sealant - per tooth |
297 |
172 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
550 |
503 |
$11K |
| D0272 |
Bitewings - two radiographic images |
1,164 |
1,047 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
200 |
168 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,530 |
1,363 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,360 |
1,211 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
38 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
84 |
70 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$421.20 |
| D1330 |
|
215 |
125 |
$0.00 |