| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
98 |
97 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
107 |
105 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
97 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
29 |
25 |
$2K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$760.50 |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
89 |
$464.80 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$273.65 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
30 |
$167.20 |