| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
87 |
87 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
118 |
118 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
105 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
87 |
87 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
113 |
$2K |
| D0274 |
Bitewings - four radiographic images |
127 |
127 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
247 |
246 |
$2K |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
192 |
192 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$725.70 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$166.35 |