| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
813 |
321 |
$65K |
| D1110 |
Prophylaxis - adult |
451 |
447 |
$18K |
| D0330 |
Panoramic radiographic image |
281 |
267 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
336 |
321 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
278 |
275 |
$8K |
| D0274 |
Bitewings - four radiographic images |
315 |
296 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
176 |
175 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
333 |
321 |
$3K |
| D1206 |
Topical application of fluoride varnish |
393 |
390 |
$3K |
| D9311 |
|
15 |
15 |
$420.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$381.60 |
| D1330 |
|
264 |
260 |
$0.00 |