| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
805 |
228 |
$49K |
| D1110 |
Prophylaxis - adult |
1,037 |
1,034 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,241 |
1,236 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
862 |
858 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
675 |
674 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,417 |
1,406 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,431 |
1,305 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
188 |
187 |
$8K |
| D1330 |
|
118 |
118 |
$989.92 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$314.00 |