| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,702 |
394 |
$137K |
| D0210 |
Intraoral - complete series of radiographic images |
1,064 |
1,064 |
$57K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
348 |
133 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,257 |
1,256 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
250 |
146 |
$29K |
| D5130 |
|
12 |
12 |
$10K |
| D2740 |
Crown - porcelain/ceramic |
21 |
12 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
143 |
140 |
$7K |
| D1110 |
Prophylaxis - adult |
105 |
104 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
29 |
$4K |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$3K |
| D1206 |
Topical application of fluoride varnish |
204 |
203 |
$2K |
| D4346 |
|
27 |
27 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
13 |
$440.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$208.50 |
| D4921 |
|
54 |
15 |
$0.00 |