| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
161 |
150 |
$4K |
| D0274 |
Bitewings - four radiographic images |
112 |
109 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
90 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
90 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
63 |
60 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$923.04 |
| D1320 |
|
80 |
73 |
$870.00 |
| D0220 |
Intraoral - periapical first radiographic image |
167 |
147 |
$635.00 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$602.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
80 |
$410.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
24 |
$345.00 |