| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
220 |
$12K |
| D1120 |
Prophylaxis - child |
217 |
210 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
191 |
184 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
35 |
24 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
83 |
83 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,187 |
376 |
$4K |
| D0274 |
Bitewings - four radiographic images |
184 |
171 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
203 |
203 |
$2K |
| D9430 |
|
102 |
98 |
$1K |
| D0240 |
|
79 |
40 |
$630.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$385.00 |
| D0350 |
|
36 |
12 |
$355.20 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
25 |
$312.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$96.00 |
| D1330 |
|
17 |
17 |
$0.00 |