| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
87 |
87 |
$2K |
| D1110 |
Prophylaxis - adult |
44 |
43 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
58 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
20 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
17 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
85 |
$1K |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$755.70 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$593.70 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$459.30 |