| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,554 |
2,554 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,629 |
2,629 |
$61K |
| D1206 |
Topical application of fluoride varnish |
1,330 |
1,330 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
607 |
327 |
$32K |
| D1351 |
Sealant - per tooth |
520 |
173 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,475 |
1,475 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,110 |
1,110 |
$15K |
| D1110 |
Prophylaxis - adult |
330 |
330 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
303 |
186 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
288 |
288 |
$7K |
| D0240 |
|
456 |
252 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
60 |
$4K |
| D0330 |
Panoramic radiographic image |
79 |
79 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
58 |
$711.76 |
| D0140 |
Limited oral evaluation - problem focused |
49 |
49 |
$633.77 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
39 |
$0.00 |
| D1999 |
|
130 |
120 |
$0.00 |