| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
331 |
328 |
$7K |
| D0330 |
Panoramic radiographic image |
63 |
63 |
$3K |
| D2954 |
|
18 |
17 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
66 |
66 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
197 |
194 |
$955.00 |
| D0120 |
Periodic oral evaluation - established patient |
49 |
49 |
$819.84 |
| D1206 |
Topical application of fluoride varnish |
50 |
50 |
$720.00 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$511.95 |
| D1120 |
Prophylaxis - child |
27 |
27 |
$480.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
16 |
$90.00 |