| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
701 |
700 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,230 |
1,229 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
780 |
778 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
830 |
828 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
188 |
87 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
440 |
439 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
180 |
$5K |
| D0274 |
Bitewings - four radiographic images |
111 |
111 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
68 |
$823.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$303.00 |