| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
410 |
405 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
368 |
360 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
426 |
423 |
$16K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
74 |
38 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
123 |
122 |
$4K |
| D0330 |
Panoramic radiographic image |
126 |
125 |
$3K |
| D1206 |
Topical application of fluoride varnish |
80 |
80 |
$1K |
| D0274 |
Bitewings - four radiographic images |
117 |
115 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
195 |
110 |
$726.90 |
| D1120 |
Prophylaxis - child |
18 |
18 |
$417.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$72.00 |