| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
599 |
112 |
$38K |
| D9243 |
|
41 |
12 |
$4K |
| D1110 |
Prophylaxis - adult |
78 |
77 |
$3K |
| D0330 |
Panoramic radiographic image |
61 |
61 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
82 |
82 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
76 |
$1K |
| D9239 |
|
12 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$700.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$104.00 |