| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
200 |
189 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
31 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
197 |
188 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
43 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
181 |
176 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
42 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
73 |
$2K |
| D0274 |
Bitewings - four radiographic images |
83 |
80 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
31 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
277 |
265 |
$1K |
| D0330 |
Panoramic radiographic image |
34 |
28 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
14 |
$67.75 |