| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
993 |
993 |
$49K |
| D0330 |
Panoramic radiographic image |
644 |
644 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
654 |
652 |
$24K |
| D0274 |
Bitewings - four radiographic images |
803 |
803 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
850 |
850 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
186 |
103 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
793 |
784 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
43 |
30 |
$6K |
| D1206 |
Topical application of fluoride varnish |
290 |
290 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$2K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$1K |