| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
801 |
801 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
757 |
756 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,136 |
1,135 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
979 |
951 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
85 |
$5K |
| D0274 |
Bitewings - four radiographic images |
163 |
163 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
254 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
15 |
$2K |
| D9430 |
|
14 |
13 |
$448.00 |