| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
206 |
197 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
29 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
149 |
$3K |
| D0274 |
Bitewings - four radiographic images |
255 |
250 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
48 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
110 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
386 |
376 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
518 |
295 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
52 |
51 |
$750.96 |