| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
785 |
785 |
$38K |
| D0272 |
Bitewings - two radiographic images |
843 |
843 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
666 |
666 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
247 |
247 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
103 |
72 |
$8K |
| D0330 |
Panoramic radiographic image |
120 |
120 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
136 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
250 |
250 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
135 |
$2K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$870.00 |