| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
465 |
343 |
$23K |
| D0330 |
Panoramic radiographic image |
305 |
305 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
384 |
384 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
36 |
31 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
99 |
$1K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$695.45 |
| D0120 |
Periodic oral evaluation - established patient |
25 |
25 |
$693.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$351.95 |