| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
513 |
513 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
165 |
119 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
409 |
409 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
188 |
188 |
$7K |
| D0330 |
Panoramic radiographic image |
104 |
104 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
248 |
242 |
$3K |
| D0274 |
Bitewings - four radiographic images |
81 |
81 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
113 |
113 |
$2K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$487.20 |