| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
856 |
855 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
977 |
973 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
138 |
51 |
$8K |
| D1206 |
Topical application of fluoride varnish |
113 |
113 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$960.00 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$780.00 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$555.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$420.00 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$280.00 |