| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,290 |
318 |
$85K |
| D0330 |
Panoramic radiographic image |
677 |
653 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
565 |
535 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
134 |
89 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
48 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
30 |
18 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
95 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
39 |
$819.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$699.05 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$638.82 |