| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
186 |
36 |
$16K |
| D1110 |
Prophylaxis - adult |
113 |
113 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
50 |
50 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
66 |
66 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$2K |
| D2160 |
|
16 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
60 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
125 |
46 |
$768.60 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$504.00 |