| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,317 |
1,317 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,040 |
1,040 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
465 |
464 |
$19K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
145 |
118 |
$14K |
| D0274 |
Bitewings - four radiographic images |
519 |
519 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
394 |
393 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
831 |
830 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
565 |
559 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
107 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
69 |
$747.14 |
| D2140 |
|
12 |
12 |
$625.96 |