| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
383 |
383 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
224 |
105 |
$15K |
| D0274 |
Bitewings - four radiographic images |
350 |
349 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
188 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
428 |
418 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
440 |
434 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
148 |
148 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
25 |
$3K |
| D9110 |
|
52 |
50 |
$2K |