| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
340 |
105 |
$23K |
| D0330 |
Panoramic radiographic image |
183 |
181 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
311 |
310 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
152 |
133 |
$6K |
| D1110 |
Prophylaxis - adult |
112 |
112 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
186 |
182 |
$5K |
| D0274 |
Bitewings - four radiographic images |
125 |
125 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
31 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
160 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$564.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
24 |
$375.74 |