| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
478 |
93 |
$54K |
| D0330 |
Panoramic radiographic image |
21 |
21 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
51 |
42 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
12 |
$223.90 |
| D0220 |
Intraoral - periapical first radiographic image |
23 |
16 |
$141.66 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
15 |
$119.91 |