| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,681 |
1,680 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,764 |
1,763 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,460 |
1,460 |
$30K |
| D0272 |
Bitewings - two radiographic images |
624 |
624 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
27 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
13 |
$937.84 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$704.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$539.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$221.00 |