| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,041 |
2,040 |
$175K |
| D0120 |
Periodic oral evaluation - established patient |
2,498 |
2,492 |
$152K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,196 |
1,195 |
$75K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,281 |
2,673 |
$57K |
| D1120 |
Prophylaxis - child |
1,397 |
1,396 |
$53K |
| D7140 |
Extraction, erupted tooth or exposed root |
889 |
569 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,524 |
3,520 |
$44K |
| D0274 |
Bitewings - four radiographic images |
936 |
936 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,063 |
1,053 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
95 |
95 |
$4K |
| D1351 |
Sealant - per tooth |
139 |
29 |
$3K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$264.00 |