| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
174 |
52 |
$10K |
| D2394 |
|
92 |
38 |
$7K |
| D0274 |
Bitewings - four radiographic images |
173 |
173 |
$3K |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
154 |
154 |
$3K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$764.15 |
| D0230 |
Intraoral - periapical each additional radiographic image |
128 |
108 |
$755.00 |
| D0220 |
Intraoral - periapical first radiographic image |
151 |
150 |
$740.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$405.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$293.54 |