| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
87 |
87 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
114 |
$3K |
| D1110 |
Prophylaxis - adult |
50 |
50 |
$2K |
| D0272 |
Bitewings - two radiographic images |
91 |
90 |
$1K |
| D1120 |
Prophylaxis - child |
18 |
18 |
$735.94 |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
13 |
$634.98 |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$598.50 |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
72 |
$524.01 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
14 |
$425.70 |