| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
342 |
312 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
224 |
217 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
79 |
79 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
35 |
25 |
$2K |
| D4355 |
|
15 |
15 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$772.40 |
| D1120 |
Prophylaxis - child |
20 |
20 |
$771.44 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$654.51 |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
80 |
$636.53 |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$623.10 |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$421.04 |