| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,446 |
747 |
$82K |
| D1110 |
Prophylaxis - adult |
770 |
770 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
688 |
686 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,103 |
2,414 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
764 |
732 |
$28K |
| D1120 |
Prophylaxis - child |
910 |
907 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,656 |
1,655 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,396 |
1,345 |
$16K |
| D1351 |
Sealant - per tooth |
475 |
121 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
911 |
908 |
$9K |
| D9430 |
|
110 |
110 |
$3K |