| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
34 |
$3K |
| D1110 |
Prophylaxis - adult |
74 |
74 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
23 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
72 |
72 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
45 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$960.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
37 |
$555.00 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$215.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$115.00 |