| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
25 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
22 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
15 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$790.50 |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$511.95 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$361.28 |
| D0220 |
Intraoral - periapical first radiographic image |
23 |
22 |
$115.00 |