| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
68 |
28 |
$3K |
| D1110 |
Prophylaxis - adult |
100 |
100 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
33 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$1K |
| D0274 |
Bitewings - four radiographic images |
66 |
65 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
69 |
69 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
37 |
$655.82 |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
82 |
$314.66 |
| D0230 |
Intraoral - periapical each additional radiographic image |
82 |
52 |
$211.05 |