| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,450 |
1,450 |
$124K |
| D0330 |
Panoramic radiographic image |
765 |
764 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
850 |
850 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
444 |
444 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
434 |
434 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
14 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
45 |
$924.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$861.00 |
| D0272 |
Bitewings - two radiographic images |
23 |
23 |
$586.50 |