| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,127 |
593 |
$63K |
| D1110 |
Prophylaxis - adult |
426 |
414 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,250 |
1,193 |
$10K |
| D0274 |
Bitewings - four radiographic images |
340 |
329 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
448 |
448 |
$9K |
| D9110 |
|
200 |
193 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
465 |
450 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
115 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
44 |
$755.04 |