| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
156 |
69 |
$7K |
| D0330 |
Panoramic radiographic image |
88 |
88 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
222 |
222 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
85 |
75 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
102 |
$2K |
| D0274 |
Bitewings - four radiographic images |
93 |
93 |
$2K |
| D1110 |
Prophylaxis - adult |
55 |
55 |
$2K |
| D2394 |
|
18 |
16 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
159 |
$745.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
55 |
$400.00 |