| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
194 |
183 |
$383.00 |
| D0120 |
Periodic oral evaluation - established patient |
248 |
240 |
$236.00 |
| D1120 |
Prophylaxis - child |
198 |
195 |
$200.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
398 |
383 |
$147.00 |
| D0274 |
Bitewings - four radiographic images |
196 |
191 |
$144.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
14 |
$79.00 |
| D0140 |
Limited oral evaluation - problem focused |
201 |
194 |
$32.00 |
| D0601 |
|
112 |
105 |
$22.00 |
| D0220 |
Intraoral - periapical first radiographic image |
170 |
158 |
$10.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
105 |
$0.00 |
| D1330 |
|
1,144 |
949 |
$0.00 |
| D0603 |
|
448 |
400 |
$0.00 |
| D0170 |
|
43 |
38 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
14 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$0.00 |
| D0602 |
|
14 |
14 |
$0.00 |
| D1354 |
|
651 |
156 |
$0.00 |
| D0330 |
Panoramic radiographic image |
94 |
91 |
$0.00 |