| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
132 |
130 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
238 |
236 |
$6K |
| D0274 |
Bitewings - four radiographic images |
146 |
145 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
213 |
212 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
51 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
95 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
48 |
47 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
198 |
172 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$721.68 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$598.00 |
| D0120 |
Periodic oral evaluation - established patient |
20 |
20 |
$257.25 |
| D9920 |
|
22 |
19 |
$0.00 |