| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
164 |
24 |
$20K |
| D7250 |
|
55 |
13 |
$7K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$3K |
| D1110 |
Prophylaxis - adult |
67 |
67 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
58 |
58 |
$788.56 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$469.77 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$267.08 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
42 |
$256.67 |