| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
69 |
12 |
$4K |
| D1110 |
Prophylaxis - adult |
77 |
51 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
81 |
$2K |
| D0330 |
Panoramic radiographic image |
77 |
55 |
$2K |
| D1206 |
Topical application of fluoride varnish |
109 |
70 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
57 |
39 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
49 |
$951.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
267 |
59 |
$922.86 |
| D0274 |
Bitewings - four radiographic images |
64 |
45 |
$780.75 |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
65 |
$614.49 |