| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,012 |
2,012 |
$57K |
| D1120 |
Prophylaxis - child |
996 |
996 |
$25K |
| D0274 |
Bitewings - four radiographic images |
916 |
916 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,804 |
1,804 |
$21K |
| D1110 |
Prophylaxis - adult |
508 |
508 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
67 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
145 |
139 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
300 |
295 |
$3K |
| D0272 |
Bitewings - two radiographic images |
158 |
158 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
30 |
16 |
$2K |
| D2140 |
|
21 |
14 |
$809.13 |