| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
162 |
37 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
192 |
191 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
57 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$2K |
| D1110 |
Prophylaxis - adult |
51 |
51 |
$2K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$2K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
226 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
58 |
58 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
104 |
44 |
$546.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$252.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$189.00 |