| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
368 |
368 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
534 |
532 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
347 |
346 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
81 |
$3K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
14 |
$988.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$728.00 |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$672.00 |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
94 |
$582.00 |
| D9920 |
|
14 |
14 |
$242.00 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$150.00 |