| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
242 |
242 |
$9K |
| D1351 |
Sealant - per tooth |
220 |
62 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
58 |
$7K |
| D1206 |
Topical application of fluoride varnish |
288 |
288 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
226 |
226 |
$6K |
| D0272 |
Bitewings - two radiographic images |
158 |
158 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
203 |
$2K |
| D9310 |
|
24 |
24 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
207 |
201 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$688.56 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$553.96 |
| D0603 |
|
28 |
28 |
$28.00 |