| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
164 |
61 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
158 |
158 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
25 |
$2K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$864.00 |
| D0120 |
Periodic oral evaluation - established patient |
21 |
21 |
$420.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$361.45 |