| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1310 |
|
149 |
149 |
$2K |
| D1120 |
Prophylaxis - child |
250 |
246 |
$2K |
| D1206 |
Topical application of fluoride varnish |
454 |
445 |
$1K |
| D0603 |
|
147 |
145 |
$646.63 |
| D0210 |
Intraoral - complete series of radiographic images |
169 |
169 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
388 |
386 |
$0.00 |
| D1330 |
|
474 |
444 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
12 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
66 |
20 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
16 |
16 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
188 |
$0.00 |
| D9430 |
|
191 |
176 |
$0.00 |
| D0330 |
Panoramic radiographic image |
131 |
128 |
$0.00 |
| D0350 |
|
115 |
95 |
$0.00 |
| D4341 |
|
17 |
12 |
$0.00 |