| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,004 |
1,995 |
$107K |
| D1120 |
Prophylaxis - child |
1,854 |
1,849 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
916 |
915 |
$57K |
| D0210 |
Intraoral - complete series of radiographic images |
1,033 |
1,029 |
$48K |
| D1206 |
Topical application of fluoride varnish |
2,377 |
2,363 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,353 |
2,671 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
368 |
219 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,434 |
1,430 |
$17K |
| D1110 |
Prophylaxis - adult |
173 |
173 |
$13K |
| D4341 |
|
114 |
29 |
$8K |
| D4910 |
|
69 |
69 |
$5K |
| D0274 |
Bitewings - four radiographic images |
205 |
205 |
$4K |
| D2140 |
|
17 |
13 |
$928.20 |