| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
522 |
519 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
665 |
662 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
534 |
311 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
584 |
567 |
$4K |
| D9110 |
|
151 |
146 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
28 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
21 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$1K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$985.74 |