| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
281 |
260 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
438 |
409 |
$10K |
| D1206 |
Topical application of fluoride varnish |
346 |
324 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
284 |
261 |
$4K |
| D0272 |
Bitewings - two radiographic images |
190 |
185 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
12 |
$4K |
| D1120 |
Prophylaxis - child |
84 |
84 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
82 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
91 |
86 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$802.81 |
| D0601 |
|
14 |
13 |
$50.00 |