| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
468 |
452 |
$15K |
| D0274 |
Bitewings - four radiographic images |
439 |
423 |
$11K |
| D0330 |
Panoramic radiographic image |
258 |
244 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
409 |
393 |
$7K |
| D1320 |
|
387 |
372 |
$6K |
| D1310 |
|
544 |
522 |
$4K |
| D1330 |
|
530 |
509 |
$4K |
| D1206 |
Topical application of fluoride varnish |
180 |
172 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
27 |
$3K |
| D9110 |
|
73 |
73 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
101 |
99 |
$2K |
| D2330 |
|
28 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$326.69 |
| D0603 |
|
12 |
12 |
$120.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$100.48 |