| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
763 |
763 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,002 |
1,002 |
$29K |
| D1120 |
Prophylaxis - child |
482 |
482 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
306 |
306 |
$9K |
| D0274 |
Bitewings - four radiographic images |
234 |
234 |
$8K |
| D0330 |
Panoramic radiographic image |
130 |
130 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
357 |
357 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
183 |
183 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
204 |
$3K |
| D0272 |
Bitewings - two radiographic images |
102 |
102 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
17 |
$1K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$715.50 |
| D0190 |
|
14 |
14 |
$0.00 |
| D9995 |
|
14 |
14 |
$0.00 |
| D1330 |
|
13 |
13 |
$0.00 |