| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
424 |
418 |
$10K |
| D1110 |
Prophylaxis - adult |
149 |
148 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
179 |
177 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
41 |
41 |
$875.80 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$745.55 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$594.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$256.80 |
| D9986 |
|
172 |
145 |
$0.00 |
| D9987 |
|
81 |
68 |
$0.00 |