| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
544 |
544 |
$8K |
| D2950 |
|
31 |
24 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
441 |
441 |
$2K |
| D0330 |
Panoramic radiographic image |
138 |
138 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
93 |
$2K |
| D0274 |
Bitewings - four radiographic images |
207 |
207 |
$2K |
| D9994 |
|
513 |
511 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
104 |
$516.48 |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
273 |
$450.43 |
| D1206 |
Topical application of fluoride varnish |
87 |
87 |
$351.39 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
39 |
$0.00 |
| D9992 |
|
12 |
12 |
$0.00 |