| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
202 |
202 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
338 |
338 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
161 |
161 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
115 |
115 |
$3K |
| D2140 |
|
45 |
32 |
$3K |
| D0274 |
Bitewings - four radiographic images |
78 |
78 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
203 |
203 |
$2K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
200 |
200 |
$2K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$1K |