| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
423 |
410 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
510 |
499 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
925 |
403 |
$8K |
| D1110 |
Prophylaxis - adult |
152 |
151 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
29 |
$6K |
| D1206 |
Topical application of fluoride varnish |
190 |
188 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
15 |
$3K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$878.36 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$364.96 |