| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
475 |
452 |
$2K |
| D1110 |
Prophylaxis - adult |
173 |
171 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
62 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
555 |
539 |
$504.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
368 |
155 |
$202.80 |
| D0274 |
Bitewings - four radiographic images |
177 |
176 |
$198.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$97.50 |
| D0120 |
Periodic oral evaluation - established patient |
62 |
61 |
$93.00 |