| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,414 |
1,408 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
2,003 |
1,982 |
$101K |
| D1120 |
Prophylaxis - child |
951 |
950 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,640 |
2,618 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,456 |
1,444 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
420 |
420 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,869 |
797 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
184 |
181 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$1K |
| D0350 |
|
86 |
40 |
$796.80 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |