| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
526 |
334 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
433 |
282 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
201 |
130 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
129 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
145 |
119 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
71 |
$11K |
| D1206 |
Topical application of fluoride varnish |
141 |
106 |
$3K |
| D1351 |
Sealant - per tooth |
18 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
12 |
$427.40 |
| D0999 |
Unspecified diagnostic procedure, by report |
447 |
289 |
$0.00 |