| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
427 |
237 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
252 |
125 |
$12K |
| D1110 |
Prophylaxis - adult |
306 |
304 |
$11K |
| D0330 |
Panoramic radiographic image |
285 |
282 |
$10K |
| D0274 |
Bitewings - four radiographic images |
337 |
334 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
416 |
413 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
132 |
82 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
118 |
117 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
328 |
326 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
148 |
138 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$325.44 |