| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
912 |
713 |
$19K |
| D2950 |
|
170 |
123 |
$14K |
| D0274 |
Bitewings - four radiographic images |
612 |
601 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
132 |
18 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
204 |
190 |
$7K |
| D0330 |
Panoramic radiographic image |
216 |
125 |
$6K |
| D1110 |
Prophylaxis - adult |
134 |
130 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
311 |
310 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
268 |
227 |
$1K |
| D4910 |
|
12 |
12 |
$887.92 |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
33 |
$677.79 |
| D0140 |
Limited oral evaluation - problem focused |
42 |
25 |
$571.09 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$569.84 |
| D9630 |
|
14 |
14 |
$278.18 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$249.48 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$0.00 |