| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
60 |
60 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$722.68 |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$470.07 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$356.67 |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
78 |
$0.00 |
| D1330 |
|
179 |
178 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
82 |
82 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$0.00 |
| D0191 |
|
12 |
12 |
$0.00 |