| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,776 |
1,773 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,092 |
2,090 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,389 |
1,389 |
$20K |
| D1206 |
Topical application of fluoride varnish |
665 |
664 |
$20K |
| D1110 |
Prophylaxis - adult |
296 |
296 |
$16K |
| D0272 |
Bitewings - two radiographic images |
564 |
562 |
$9K |
| D0330 |
Panoramic radiographic image |
77 |
77 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
78 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$1K |