| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
627 |
627 |
$23K |
| D1120 |
Prophylaxis - child |
508 |
508 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
416 |
416 |
$5K |
| D0272 |
Bitewings - two radiographic images |
242 |
242 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
27 |
$3K |
| D1351 |
Sealant - per tooth |
40 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$999.00 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$783.20 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$733.75 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$520.55 |
| D1206 |
Topical application of fluoride varnish |
22 |
22 |
$498.30 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$349.30 |
| D1330 |
|
241 |
241 |
$0.00 |
| D0602 |
|
127 |
127 |
$0.00 |
| D1310 |
|
20 |
20 |
$0.00 |
| D0603 |
|
14 |
14 |
$0.00 |