| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
344 |
177 |
$20K |
| D1110 |
Prophylaxis - adult |
448 |
446 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
187 |
112 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
220 |
220 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
355 |
354 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
328 |
326 |
$6K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
103 |
$820.55 |
| D9110 |
|
24 |
24 |
$738.00 |
| D1330 |
|
137 |
137 |
$671.48 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$542.45 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
52 |
$522.25 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$406.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$315.00 |