| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
535 |
205 |
$52K |
| D1110 |
Prophylaxis - adult |
391 |
370 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
253 |
243 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
400 |
376 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
225 |
205 |
$7K |
| D0274 |
Bitewings - four radiographic images |
238 |
220 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
13 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
225 |
215 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
12 |
$703.92 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$226.10 |