| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
204 |
101 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
194 |
61 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
148 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
179 |
174 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
496 |
476 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
133 |
132 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
235 |
214 |
$969.25 |
| D1110 |
Prophylaxis - adult |
72 |
72 |
$808.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$495.50 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$35.00 |