| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
240 |
118 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
91 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
81 |
53 |
$13K |
| D1110 |
Prophylaxis - adult |
204 |
196 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
197 |
193 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
29 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
135 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
233 |
225 |
$5K |
| D0274 |
Bitewings - four radiographic images |
128 |
126 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
231 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
47 |
$637.06 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.72 |