| Code | Description | Claims | Beneficiaries | Total Paid |
| D4341 |
|
236 |
85 |
$31K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
91 |
64 |
$8K |
| D1120 |
Prophylaxis - child |
168 |
167 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
237 |
237 |
$7K |
| D1354 |
|
424 |
102 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
202 |
$4K |
| D0274 |
Bitewings - four radiographic images |
216 |
216 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
139 |
139 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
47 |
$4K |
| D2750 |
|
12 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
487 |
476 |
$3K |
| D1110 |
Prophylaxis - adult |
61 |
61 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
173 |
169 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
44 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
35 |
$3K |
| D1206 |
Topical application of fluoride varnish |
153 |
143 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
358 |
356 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$1K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$992.90 |
| D4910 |
|
12 |
12 |
$737.00 |
| D0272 |
Bitewings - two radiographic images |
47 |
47 |
$499.05 |
| D0270 |
|
56 |
56 |
$308.00 |
| D0191 |
|
136 |
126 |
$62.70 |
| D1330 |
|
34 |
33 |
$0.00 |
| D0602 |
|
44 |
39 |
$0.00 |
| D0603 |
|
105 |
99 |
$0.00 |