| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
516 |
221 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
311 |
308 |
$6K |
| D1110 |
Prophylaxis - adult |
113 |
113 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
141 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
244 |
240 |
$1K |
| D0274 |
Bitewings - four radiographic images |
77 |
76 |
$924.00 |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$546.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$315.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
39 |
$252.00 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$177.24 |