| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
136 |
136 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
171 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
45 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
88 |
88 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
99 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
17 |
$1K |
| D1120 |
Prophylaxis - child |
61 |
61 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$555.84 |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
61 |
$310.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
27 |
$230.00 |