| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
509 |
260 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
227 |
125 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
376 |
362 |
$10K |
| D1110 |
Prophylaxis - adult |
218 |
217 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
264 |
263 |
$9K |
| D0274 |
Bitewings - four radiographic images |
279 |
276 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
597 |
557 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
46 |
31 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
15 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
43 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
42 |
$576.07 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$245.74 |