| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
26 |
$9K |
| D1110 |
Prophylaxis - adult |
121 |
121 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
29 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$5K |
| D0330 |
Panoramic radiographic image |
84 |
84 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$3K |
| D1206 |
Topical application of fluoride varnish |
110 |
110 |
$3K |
| D0274 |
Bitewings - four radiographic images |
96 |
96 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
109 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
26 |
26 |
$827.06 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$614.38 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$104.96 |