| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
808 |
803 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
679 |
675 |
$14K |
| D0274 |
Bitewings - four radiographic images |
388 |
386 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
65 |
$9K |
| D0330 |
Panoramic radiographic image |
149 |
148 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
213 |
213 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
109 |
107 |
$2K |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$464.00 |