| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
834 |
834 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
309 |
193 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
794 |
792 |
$22K |
| D1351 |
Sealant - per tooth |
358 |
116 |
$14K |
| D1206 |
Topical application of fluoride varnish |
401 |
401 |
$11K |
| D0272 |
Bitewings - two radiographic images |
475 |
475 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
565 |
564 |
$8K |
| D1110 |
Prophylaxis - adult |
132 |
131 |
$7K |
| D0240 |
|
258 |
133 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
152 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
265 |
265 |
$3K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
134 |
134 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$1K |