| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
3,617 |
1,052 |
$180K |
| D1110 |
Prophylaxis - adult |
1,621 |
1,616 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
1,328 |
1,324 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
695 |
689 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
167 |
167 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
616 |
609 |
$9K |
| D0330 |
Panoramic radiographic image |
188 |
187 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
536 |
527 |
$4K |
| D0274 |
Bitewings - four radiographic images |
130 |
129 |
$3K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$520.73 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$205.00 |