| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
234 |
232 |
$10K |
| D1110 |
Prophylaxis - adult |
144 |
144 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
125 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
19 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
25 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
274 |
273 |
$3K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
53 |
53 |
$1K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$917.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
13 |
$216.26 |