| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
65 |
18 |
$3K |
| D1110 |
Prophylaxis - adult |
107 |
106 |
$3K |
| D0330 |
Panoramic radiographic image |
69 |
58 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
15 |
$387.12 |
| D0120 |
Periodic oral evaluation - established patient |
26 |
26 |
$356.99 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$276.00 |
| D0140 |
Limited oral evaluation - problem focused |
21 |
12 |
$203.22 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$63.00 |