| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
22 |
$1K |
| D1110 |
Prophylaxis - adult |
52 |
43 |
$1K |
| D0274 |
Bitewings - four radiographic images |
71 |
58 |
$590.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
31 |
$481.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
142 |
61 |
$462.60 |
| D0120 |
Periodic oral evaluation - established patient |
34 |
30 |
$420.24 |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
74 |
$391.10 |
| D0140 |
Limited oral evaluation - problem focused |
21 |
14 |
$136.00 |