| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
264 |
264 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
149 |
82 |
$13K |
| D0274 |
Bitewings - four radiographic images |
235 |
235 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
199 |
199 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
231 |
230 |
$3K |
| D0330 |
Panoramic radiographic image |
74 |
74 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
93 |
$3K |
| D1120 |
Prophylaxis - child |
47 |
47 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
191 |
191 |
$2K |
| D1206 |
Topical application of fluoride varnish |
32 |
32 |
$960.00 |
| D0140 |
Limited oral evaluation - problem focused |
67 |
63 |
$938.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$364.00 |