| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9110 |
|
405 |
315 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
549 |
424 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
118 |
118 |
$3K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
36 |
36 |
$936.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$615.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
84 |
83 |
$567.84 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$509.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
117 |
$486.72 |