| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
857 |
841 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,010 |
987 |
$21K |
| D0330 |
Panoramic radiographic image |
371 |
360 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
217 |
110 |
$15K |
| D0272 |
Bitewings - two radiographic images |
712 |
699 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
994 |
654 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
24 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$377.00 |