| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
726 |
611 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
957 |
772 |
$12K |
| D0330 |
Panoramic radiographic image |
455 |
353 |
$8K |
| D0274 |
Bitewings - four radiographic images |
619 |
522 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
207 |
100 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
498 |
386 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
211 |
84 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
73 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
495 |
349 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
209 |
200 |
$443.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
105 |
35 |
$100.62 |
| D1120 |
Prophylaxis - child |
47 |
47 |
$0.00 |
| D2950 |
|
38 |
28 |
$0.00 |
| D4341 |
|
39 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
128 |
128 |
$0.00 |
| D9994 |
|
395 |
395 |
$0.00 |
| D9630 |
|
389 |
389 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
209 |
209 |
$0.00 |
| D2750 |
|
18 |
13 |
$0.00 |