| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
547 |
547 |
$21K |
| D0274 |
Bitewings - four radiographic images |
425 |
424 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
199 |
134 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
340 |
340 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
282 |
282 |
$6K |
| D0330 |
Panoramic radiographic image |
112 |
112 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
218 |
217 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
15 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
50 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$996.10 |