| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
590 |
590 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
423 |
395 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
441 |
441 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
526 |
526 |
$8K |
| D0330 |
Panoramic radiographic image |
170 |
170 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
145 |
$6K |
| D0274 |
Bitewings - four radiographic images |
188 |
188 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
41 |
$538.86 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$417.60 |