| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
546 |
546 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
253 |
217 |
$12K |
| D0272 |
Bitewings - two radiographic images |
168 |
168 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
62 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
27 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
25 |
$769.92 |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$0.00 |