| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
532 |
532 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
287 |
286 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
75 |
46 |
$7K |
| D0274 |
Bitewings - four radiographic images |
239 |
239 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
443 |
430 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
96 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
108 |
$1K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$867.55 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$740.00 |