| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
34 |
30 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
67 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$975.80 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$894.65 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$884.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
35 |
$736.75 |
| D0120 |
Periodic oral evaluation - established patient |
19 |
19 |
$532.00 |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
30 |
$173.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
17 |
$98.80 |