| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
654 |
629 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
882 |
838 |
$2K |
| D1110 |
Prophylaxis - adult |
85 |
84 |
$1K |
| D0274 |
Bitewings - four radiographic images |
147 |
147 |
$620.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
372 |
303 |
$502.95 |
| D1120 |
Prophylaxis - child |
14 |
13 |
$273.00 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$215.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$204.75 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$121.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
92 |
43 |
$103.00 |