| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
164 |
162 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
164 |
162 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
15 |
$3K |
| D0330 |
Panoramic radiographic image |
61 |
61 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
60 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
55 |
$933.20 |
| D0274 |
Bitewings - four radiographic images |
72 |
72 |
$766.12 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$338.00 |
| D0220 |
Intraoral - periapical first radiographic image |
22 |
17 |
$113.47 |
| D0270 |
|
12 |
12 |
$67.20 |