| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
293 |
291 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
365 |
364 |
$10K |
| D1351 |
Sealant - per tooth |
229 |
72 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
288 |
286 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
56 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
82 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
254 |
244 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
211 |
188 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$988.05 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$910.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$461.76 |