| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
53 |
53 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$900.00 |
| D0120 |
Periodic oral evaluation - established patient |
37 |
37 |
$631.96 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
23 |
23 |
$606.05 |
| D0140 |
Limited oral evaluation - problem focused |
23 |
23 |
$519.34 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$480.00 |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
79 |
$420.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
34 |
$385.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
22 |
22 |
$300.00 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$280.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$150.00 |