| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
92 |
37 |
$5K |
| D1110 |
Prophylaxis - adult |
86 |
86 |
$3K |
| D0274 |
Bitewings - four radiographic images |
81 |
81 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
98 |
98 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
54 |
$1K |
| D0330 |
Panoramic radiographic image |
22 |
22 |
$972.72 |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
14 |
$607.36 |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
95 |
$455.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
32 |
$430.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$263.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$240.00 |