| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
238 |
210 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
272 |
233 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
103 |
103 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
35 |
$2K |
| D1206 |
Topical application of fluoride varnish |
123 |
96 |
$2K |
| D0274 |
Bitewings - four radiographic images |
123 |
106 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
30 |
$1K |
| D1351 |
Sealant - per tooth |
23 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
251 |
209 |
$901.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
209 |
174 |
$585.20 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
13 |
$353.65 |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$300.80 |
| D9310 |
|
31 |
25 |
$290.70 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$287.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$178.20 |