| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
266 |
266 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
139 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
49 |
18 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
37 |
37 |
$1K |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$783.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
37 |
$252.00 |