| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
229 |
157 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
204 |
141 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
533 |
383 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
186 |
118 |
$1K |
| D0274 |
Bitewings - four radiographic images |
231 |
151 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
26 |
16 |
$768.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$684.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
45 |
$672.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
323 |
195 |
$580.20 |
| D1330 |
|
13 |
13 |
$0.00 |