| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
4,066 |
960 |
$183K |
| D0330 |
Panoramic radiographic image |
1,240 |
1,216 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,244 |
1,219 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
396 |
298 |
$28K |
| D1110 |
Prophylaxis - adult |
949 |
937 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
502 |
361 |
$24K |
| D4355 |
|
314 |
307 |
$19K |
| D2331 |
|
116 |
65 |
$7K |
| D0274 |
Bitewings - four radiographic images |
465 |
458 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
354 |
348 |
$3K |
| D2330 |
|
19 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
220 |
212 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$725.05 |
| D4346 |
|
12 |
12 |
$566.28 |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$282.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
132 |
70 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$0.00 |
| D4910 |
|
86 |
86 |
$0.00 |