| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
597 |
188 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
233 |
212 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
262 |
260 |
$6K |
| D1110 |
Prophylaxis - adult |
155 |
154 |
$6K |
| D0330 |
Panoramic radiographic image |
167 |
164 |
$6K |
| D0274 |
Bitewings - four radiographic images |
148 |
147 |
$3K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
289 |
272 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
112 |
112 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
13 |
$967.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
31 |
$378.90 |
| D9986 |
|
444 |
355 |
$0.00 |