| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
520 |
166 |
$36K |
| D0330 |
Panoramic radiographic image |
312 |
312 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
228 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
256 |
246 |
$6K |
| D1120 |
Prophylaxis - child |
100 |
100 |
$3K |
| D1110 |
Prophylaxis - adult |
51 |
51 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
96 |
94 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
82 |
74 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
27 |
$525.44 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$386.40 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$249.48 |