| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
312 |
312 |
$12K |
| D1206 |
Topical application of fluoride varnish |
305 |
305 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
179 |
179 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
45 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
105 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
30 |
$1K |
| D0274 |
Bitewings - four radiographic images |
66 |
66 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
147 |
$945.23 |
| D0230 |
Intraoral - periapical each additional radiographic image |
166 |
138 |
$878.08 |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$692.40 |
| D0272 |
Bitewings - two radiographic images |
52 |
52 |
$541.17 |