| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
285 |
207 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
305 |
229 |
$10K |
| D1206 |
Topical application of fluoride varnish |
282 |
201 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
78 |
62 |
$2K |
| D0274 |
Bitewings - four radiographic images |
162 |
123 |
$2K |
| D2394 |
|
19 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
160 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
69 |
48 |
$1K |
| D0272 |
Bitewings - two radiographic images |
126 |
75 |
$924.63 |
| D0120 |
Periodic oral evaluation - established patient |
40 |
16 |
$610.18 |
| D0230 |
Intraoral - periapical each additional radiographic image |
158 |
132 |
$396.00 |