| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
512 |
188 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
871 |
661 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
313 |
96 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
885 |
631 |
$19K |
| D1120 |
Prophylaxis - child |
946 |
676 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
333 |
61 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
870 |
622 |
$9K |
| D0330 |
Panoramic radiographic image |
152 |
121 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
307 |
219 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
46 |
27 |
$709.26 |