| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,368 |
2,366 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,366 |
2,364 |
$47K |
| D0274 |
Bitewings - four radiographic images |
2,360 |
2,357 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,369 |
2,218 |
$19K |
| D0330 |
Panoramic radiographic image |
607 |
606 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,992 |
1,980 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
117 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
193 |
193 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
25 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$264.40 |
| D1999 |
|
22 |
22 |
$0.00 |