| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
158 |
157 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
27 |
$4K |
| D0274 |
Bitewings - four radiographic images |
145 |
144 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
269 |
263 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
93 |
93 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
48 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
203 |
165 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$878.00 |