| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
159 |
158 |
$2K |
| D1206 |
Topical application of fluoride varnish |
330 |
329 |
$1K |
| D0274 |
Bitewings - four radiographic images |
146 |
145 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
194 |
193 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
375 |
159 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
235 |
$988.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$950.00 |
| D4910 |
|
36 |
36 |
$700.00 |
| D0140 |
Limited oral evaluation - problem focused |
53 |
53 |
$665.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
13 |
$160.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$116.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$80.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
13 |
12 |
$0.00 |