| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
769 |
766 |
$34K |
| D0274 |
Bitewings - four radiographic images |
706 |
706 |
$20K |
| D1120 |
Prophylaxis - child |
501 |
501 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
419 |
419 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
547 |
546 |
$10K |
| D0330 |
Panoramic radiographic image |
201 |
201 |
$10K |
| D4346 |
|
75 |
45 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
220 |
220 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
68 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$867.04 |