| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
894 |
320 |
$44K |
| D1110 |
Prophylaxis - adult |
373 |
372 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
457 |
456 |
$12K |
| D0272 |
Bitewings - two radiographic images |
391 |
388 |
$6K |
| D0330 |
Panoramic radiographic image |
100 |
100 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
121 |
121 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
93 |
92 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$169.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$168.05 |