| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
14 |
$3K |
| D1110 |
Prophylaxis - adult |
83 |
82 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
61 |
61 |
$1K |
| D0274 |
Bitewings - four radiographic images |
29 |
28 |
$828.80 |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
71 |
$587.52 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
36 |
$355.92 |
| D0120 |
Periodic oral evaluation - established patient |
17 |
17 |
$348.00 |