| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
770 |
752 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
981 |
950 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
165 |
162 |
$9K |
| D1206 |
Topical application of fluoride varnish |
938 |
915 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
222 |
211 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
101 |
99 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
28 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
478 |
463 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
598 |
570 |
$694.25 |
| D1120 |
Prophylaxis - child |
45 |
44 |
$180.96 |
| D1330 |
|
157 |
154 |
$84.00 |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$0.00 |