| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
336 |
335 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
269 |
269 |
$7K |
| D1206 |
Topical application of fluoride varnish |
377 |
377 |
$7K |
| D0274 |
Bitewings - four radiographic images |
187 |
186 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
101 |
$4K |
| D0602 |
|
370 |
370 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
13 |
$2K |
| D1999 |
|
171 |
124 |
$1K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
54 |
$728.00 |
| D1330 |
|
39 |
39 |
$0.00 |
| D1310 |
|
39 |
39 |
$0.00 |