| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
340 |
286 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
27 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
478 |
432 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
166 |
147 |
$955.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$510.00 |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$450.00 |
| D0274 |
Bitewings - four radiographic images |
131 |
101 |
$271.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
91 |
86 |
$229.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
54 |
$73.00 |
| D1354 |
|
155 |
24 |
$28.00 |
| D0601 |
|
23 |
12 |
$0.00 |