| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,082 |
802 |
$71K |
| D0140 |
Limited oral evaluation - problem focused |
1,097 |
1,089 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
927 |
918 |
$8K |
| D0330 |
Panoramic radiographic image |
59 |
58 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
48 |
48 |
$1K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$839.88 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$340.20 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$198.00 |