| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
805 |
805 |
$19K |
| D1110 |
Prophylaxis - adult |
139 |
139 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
27 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
262 |
262 |
$4K |
| D1120 |
Prophylaxis - child |
90 |
90 |
$3K |
| D0272 |
Bitewings - two radiographic images |
85 |
85 |
$2K |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
115 |
$1K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$1K |