| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
724 |
84 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
52 |
$7K |
| D0330 |
Panoramic radiographic image |
179 |
179 |
$6K |
| D0274 |
Bitewings - four radiographic images |
178 |
176 |
$5K |
| D1110 |
Prophylaxis - adult |
130 |
128 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
24 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
151 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
29 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
120 |
116 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
56 |
$340.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$280.80 |