| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
385 |
383 |
$2K |
| D1110 |
Prophylaxis - adult |
353 |
353 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
155 |
$840.00 |
| D0220 |
Intraoral - periapical first radiographic image |
437 |
430 |
$564.00 |
| D0210 |
Intraoral - complete series of radiographic images |
106 |
106 |
$532.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
358 |
358 |
$414.00 |
| D0274 |
Bitewings - four radiographic images |
262 |
262 |
$378.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
78 |
32 |
$192.00 |