| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
666 |
657 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
377 |
377 |
$13K |
| D0330 |
Panoramic radiographic image |
244 |
244 |
$11K |
| D0274 |
Bitewings - four radiographic images |
463 |
463 |
$11K |
| D1110 |
Prophylaxis - adult |
215 |
215 |
$9K |
| D1120 |
Prophylaxis - child |
145 |
145 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
281 |
280 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
54 |
54 |
$978.80 |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$918.00 |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$630.71 |