| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
335 |
330 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
438 |
432 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
73 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
497 |
490 |
$408.60 |
| D0274 |
Bitewings - four radiographic images |
232 |
228 |
$352.00 |
| D0120 |
Periodic oral evaluation - established patient |
56 |
55 |
$141.24 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$23.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
12 |
$8.40 |