| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
94 |
32 |
$5K |
| D1110 |
Prophylaxis - adult |
122 |
118 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
101 |
$3K |
| D0274 |
Bitewings - four radiographic images |
100 |
96 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
81 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
55 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
83 |
83 |
$1K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$555.84 |
| D0272 |
Bitewings - two radiographic images |
35 |
35 |
$350.00 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
30 |
$155.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
22 |
14 |
$110.00 |