| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
197 |
196 |
$13K |
| D1110 |
Prophylaxis - adult |
136 |
136 |
$12K |
| D0350 |
|
841 |
211 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
55 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
147 |
147 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
126 |
54 |
$7K |
| D4341 |
|
82 |
21 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
24 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
175 |
175 |
$3K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$1K |
| D9430 |
|
30 |
29 |
$960.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$630.00 |