| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
118 |
118 |
$4K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$2K |
| D1206 |
Topical application of fluoride varnish |
66 |
66 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
15 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
17 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
73 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$745.30 |
| D0274 |
Bitewings - four radiographic images |
19 |
19 |
$713.00 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$674.00 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$243.90 |
| D0190 |
|
16 |
15 |
$0.00 |