| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
76 |
75 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
16 |
$2K |
| D0274 |
Bitewings - four radiographic images |
79 |
78 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
108 |
106 |
$658.00 |
| D0140 |
Limited oral evaluation - problem focused |
39 |
38 |
$544.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
84 |
$529.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
17 |
$449.00 |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$366.08 |