| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
774 |
766 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
330 |
204 |
$28K |
| D1110 |
Prophylaxis - adult |
290 |
290 |
$14K |
| D0330 |
Panoramic radiographic image |
293 |
293 |
$14K |
| D0274 |
Bitewings - four radiographic images |
469 |
469 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
220 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
468 |
467 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
42 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
48 |
48 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$843.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$131.87 |