| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D5110 |
|
66 |
65 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
561 |
177 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
1,094 |
1,064 |
$17K |
| D0330 |
Panoramic radiographic image |
386 |
385 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
886 |
840 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
997 |
491 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
127 |
127 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$1K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$477.26 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$251.72 |