| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
18 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
173 |
173 |
$4K |
| D1110 |
Prophylaxis - adult |
71 |
71 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
75 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$790.50 |
| D1120 |
Prophylaxis - child |
39 |
39 |
$780.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$443.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
18 |
$338.45 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$177.17 |