| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
611 |
611 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
615 |
615 |
$41K |
| D9430 |
|
520 |
451 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
206 |
201 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,465 |
522 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
82 |
51 |
$9K |
| D1206 |
Topical application of fluoride varnish |
481 |
481 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
296 |
296 |
$4K |
| D4341 |
|
48 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
65 |
$3K |
| D0330 |
Panoramic radiographic image |
100 |
100 |
$3K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$3K |
| D0350 |
|
194 |
69 |
$2K |
| D4910 |
|
12 |
12 |
$924.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$633.50 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$276.00 |