| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
680 |
678 |
$38K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
169 |
166 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
628 |
624 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
200 |
198 |
$8K |
| D0274 |
Bitewings - four radiographic images |
156 |
156 |
$4K |
| D9243 |
|
12 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
131 |
128 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
82 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$1K |
| D9239 |
|
12 |
12 |
$876.00 |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$726.40 |
| D9310 |
|
42 |
42 |
$419.34 |
| D9430 |
|
12 |
12 |
$246.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$168.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$91.00 |