| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
308 |
308 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
294 |
294 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
321 |
321 |
$2K |
| D1351 |
Sealant - per tooth |
243 |
54 |
$2K |
| D0273 |
|
222 |
222 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
42 |
$878.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
33 |
$473.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
13 |
$120.75 |