| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
244 |
243 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
160 |
160 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
56 |
39 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
207 |
$947.00 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$845.00 |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$612.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$511.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
119 |
$447.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$270.00 |