| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
484 |
483 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
596 |
589 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
91 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
43 |
42 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
114 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$958.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$765.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
13 |
$256.00 |