| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
246 |
222 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
477 |
468 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
145 |
54 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
382 |
382 |
$8K |
| D1120 |
Prophylaxis - child |
127 |
127 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
118 |
$3K |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$2K |
| D1206 |
Topical application of fluoride varnish |
80 |
73 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
51 |
$2K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$358.80 |