| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
12 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
29 |
$3K |
| D1110 |
Prophylaxis - adult |
34 |
33 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
63 |
62 |
$996.48 |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$828.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
26 |
$685.35 |
| D1120 |
Prophylaxis - child |
30 |
29 |
$480.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
44 |
$420.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
15 |
$145.00 |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
17 |
$85.00 |