| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
147 |
49 |
$6K |
| D1110 |
Prophylaxis - adult |
47 |
46 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
57 |
$1K |
| D0274 |
Bitewings - four radiographic images |
54 |
53 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
34 |
34 |
$935.00 |
| D0140 |
Limited oral evaluation - problem focused |
64 |
64 |
$875.00 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$450.00 |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
80 |
$438.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$288.00 |