| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
564 |
420 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
489 |
335 |
$12K |
| D1310 |
|
286 |
192 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
527 |
397 |
$9K |
| D1330 |
|
424 |
327 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
16 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
107 |
104 |
$861.35 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
22 |
14 |
$770.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
49 |
$653.40 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$349.85 |
| D1206 |
Topical application of fluoride varnish |
152 |
147 |
$25.27 |
| D0240 |
|
47 |
24 |
$0.00 |