| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
582 |
582 |
$33K |
| D1120 |
Prophylaxis - child |
364 |
364 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
226 |
226 |
$7K |
| D0274 |
Bitewings - four radiographic images |
125 |
125 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
91 |
41 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$878.00 |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$810.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
25 |
$388.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$194.00 |
| D1999 |
|
81 |
76 |
$0.00 |