| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,681 |
1,681 |
$84K |
| D0274 |
Bitewings - four radiographic images |
1,623 |
1,623 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,757 |
1,757 |
$40K |
| D0330 |
Panoramic radiographic image |
550 |
550 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,260 |
1,260 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
409 |
409 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
107 |
65 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
327 |
327 |
$13K |
| D1120 |
Prophylaxis - child |
341 |
341 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
568 |
557 |
$7K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$227.28 |