| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
80 |
51 |
$4K |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$2K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
109 |
109 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
68 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
88 |
$1K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$390.00 |