| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
351 |
351 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
307 |
307 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
221 |
221 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,207 |
545 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
508 |
508 |
$6K |
| D0272 |
Bitewings - two radiographic images |
384 |
382 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$873.60 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
13 |
$746.20 |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
66 |
$660.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$300.00 |