| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
304 |
81 |
$25K |
| D1110 |
Prophylaxis - adult |
573 |
566 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
628 |
626 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
96 |
59 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
681 |
658 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
133 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
61 |
61 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
91 |
$3K |
| D0274 |
Bitewings - four radiographic images |
91 |
91 |
$3K |
| D2160 |
|
21 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$955.42 |
| D0230 |
Intraoral - periapical each additional radiographic image |
141 |
74 |
$932.40 |