| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
104 |
103 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
116 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
18 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$451.60 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$280.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$240.00 |
| D0210 |
Intraoral - complete series of radiographic images |
23 |
13 |
$123.12 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$105.00 |