| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
326 |
262 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
208 |
205 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
245 |
244 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
167 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,776 |
349 |
$7K |
| D4341 |
|
112 |
30 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
30 |
12 |
$4K |
| D1120 |
Prophylaxis - child |
81 |
81 |
$2K |
| D0330 |
Panoramic radiographic image |
91 |
91 |
$2K |
| D9110 |
|
15 |
15 |
$945.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
60 |
60 |
$540.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$247.50 |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$174.00 |