| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
591 |
591 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
455 |
455 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
134 |
134 |
$5K |
| D0274 |
Bitewings - four radiographic images |
180 |
180 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
318 |
313 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
30 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
181 |
181 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$397.86 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$305.20 |