| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
339 |
339 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
320 |
320 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
12 |
$4K |
| D1110 |
Prophylaxis - adult |
87 |
87 |
$4K |
| D1120 |
Prophylaxis - child |
114 |
114 |
$3K |
| D1206 |
Topical application of fluoride varnish |
73 |
73 |
$1K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$427.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$386.45 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$244.02 |