| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
233 |
233 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
309 |
309 |
$6K |
| D0274 |
Bitewings - four radiographic images |
256 |
256 |
$5K |
| D1206 |
Topical application of fluoride varnish |
212 |
212 |
$5K |
| D9990 |
|
206 |
204 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
320 |
320 |
$3K |
| D1351 |
Sealant - per tooth |
60 |
17 |
$2K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
308 |
308 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
87 |
87 |
$950.95 |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$630.26 |