| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
245 |
87 |
$17K |
| D1110 |
Prophylaxis - adult |
246 |
246 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
353 |
353 |
$9K |
| D1999 |
|
591 |
529 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
45 |
25 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
153 |
153 |
$4K |
| D0330 |
Panoramic radiographic image |
145 |
145 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$2K |
| D1120 |
Prophylaxis - child |
45 |
45 |
$1K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$1K |
| D1206 |
Topical application of fluoride varnish |
44 |
44 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
105 |
$588.20 |