| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
80 |
80 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
28 |
$2K |
| D0274 |
Bitewings - four radiographic images |
71 |
71 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
18 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
59 |
59 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
34 |
$644.80 |
| D0220 |
Intraoral - periapical first radiographic image |
84 |
84 |
$631.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
70 |
$554.96 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
18 |
$395.42 |