| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
728 |
728 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
624 |
622 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
68 |
25 |
$7K |
| D0274 |
Bitewings - four radiographic images |
154 |
154 |
$6K |
| D1120 |
Prophylaxis - child |
66 |
64 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
204 |
200 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$936.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
24 |
$460.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
14 |
$198.00 |