| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,475 |
1,459 |
$129K |
| D0999 |
Unspecified diagnostic procedure, by report |
185 |
176 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
489 |
480 |
$132.19 |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
557 |
549 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
103 |
103 |
$0.00 |
| D1351 |
Sealant - per tooth |
20 |
20 |
$0.00 |