| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
482 |
479 |
$15K |
| D0274 |
Bitewings - four radiographic images |
411 |
408 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
171 |
78 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
371 |
368 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
534 |
522 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
462 |
437 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
141 |
141 |
$3K |
| D1320 |
|
161 |
161 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$731.26 |
| D9110 |
|
26 |
24 |
$685.35 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$565.24 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$258.69 |
| D1330 |
|
108 |
107 |
$200.00 |