| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
453 |
441 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
707 |
684 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
641 |
615 |
$10K |
| D0274 |
Bitewings - four radiographic images |
250 |
245 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
175 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
43 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
82 |
$852.51 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$782.87 |
| D1999 |
|
14 |
13 |
$0.00 |