| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
262 |
262 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
112 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
142 |
142 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
107 |
25 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
301 |
301 |
$5K |
| D0274 |
Bitewings - four radiographic images |
211 |
211 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
149 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
122 |
122 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
236 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
149 |
149 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$580.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$555.84 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$150.00 |