| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
975 |
973 |
$19K |
| D0330 |
Panoramic radiographic image |
881 |
880 |
$17K |
| D1110 |
Prophylaxis - adult |
544 |
544 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
368 |
368 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
201 |
95 |
$6K |
| D9110 |
|
123 |
123 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
258 |
258 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
52 |
52 |
$312.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$240.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
75 |
$225.00 |