| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,181 |
257 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
377 |
367 |
$7K |
| D1110 |
Prophylaxis - adult |
94 |
87 |
$3K |
| D0330 |
Panoramic radiographic image |
92 |
87 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
17 |
$3K |
| D9110 |
|
46 |
44 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
119 |
$848.00 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$720.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$280.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$196.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
15 |
$56.00 |