| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
433 |
426 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
309 |
303 |
$5K |
| D1110 |
Prophylaxis - adult |
206 |
205 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
281 |
254 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$1K |
| D4355 |
|
52 |
52 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
26 |
14 |
$863.18 |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$544.36 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$345.87 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$300.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
26 |
$121.21 |