| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
121 |
32 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
202 |
164 |
$5K |
| D0330 |
Panoramic radiographic image |
141 |
112 |
$4K |
| D1120 |
Prophylaxis - child |
54 |
51 |
$2K |
| D0274 |
Bitewings - four radiographic images |
110 |
85 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
57 |
$1K |
| D1206 |
Topical application of fluoride varnish |
19 |
19 |
$906.10 |
| D4355 |
|
54 |
34 |
$714.49 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
27 |
$489.20 |
| D0350 |
|
73 |
31 |
$410.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
24 |
$152.64 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$76.57 |
| D0602 |
|
13 |
13 |
$60.00 |