| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
195 |
195 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
176 |
176 |
$4K |
| D1351 |
Sealant - per tooth |
24 |
24 |
$3K |
| D1206 |
Topical application of fluoride varnish |
81 |
81 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
25 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
154 |
154 |
$2K |
| D0272 |
Bitewings - two radiographic images |
107 |
107 |
$1K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
97 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$757.08 |
| D0230 |
Intraoral - periapical each additional radiographic image |
90 |
90 |
$543.80 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
14 |
$501.60 |
| D0274 |
Bitewings - four radiographic images |
20 |
20 |
$418.84 |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$265.81 |