| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
133 |
129 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
77 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
85 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
14 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
81 |
80 |
$966.64 |
| D0120 |
Periodic oral evaluation - established patient |
70 |
69 |
$921.79 |
| D9110 |
|
31 |
31 |
$721.38 |
| D0274 |
Bitewings - four radiographic images |
43 |
42 |
$699.17 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
39 |
$289.34 |
| D1120 |
Prophylaxis - child |
14 |
13 |
$278.66 |