| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
220 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
186 |
186 |
$9K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$5K |
| D0350 |
|
305 |
108 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
97 |
95 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$540.00 |
| D9430 |
|
14 |
14 |
$448.00 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
26 |
$396.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$259.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
41 |
$234.90 |