| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
171 |
$10K |
| D0330 |
Panoramic radiographic image |
112 |
112 |
$10K |
| D1110 |
Prophylaxis - adult |
112 |
112 |
$7K |
| D0274 |
Bitewings - four radiographic images |
152 |
152 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
238 |
231 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
316 |
162 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
15 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
50 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$486.24 |