| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,392 |
1,061 |
$40K |
| D1999 |
|
2,002 |
1,576 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
872 |
621 |
$18K |
| D0330 |
Panoramic radiographic image |
524 |
367 |
$15K |
| D0272 |
Bitewings - two radiographic images |
908 |
675 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
463 |
362 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
126 |
78 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$340.17 |
| D1120 |
Prophylaxis - child |
14 |
13 |
$278.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$61.80 |