| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
379 |
234 |
$21K |
| D1110 |
Prophylaxis - adult |
621 |
618 |
$21K |
| D0330 |
Panoramic radiographic image |
393 |
388 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
781 |
777 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
274 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
263 |
262 |
$4K |
| D1120 |
Prophylaxis - child |
140 |
140 |
$3K |
| D0272 |
Bitewings - two radiographic images |
142 |
142 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
256 |
252 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
139 |
131 |
$716.25 |