| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
671 |
117 |
$59K |
| D2740 |
Crown - porcelain/ceramic |
85 |
47 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
904 |
903 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,198 |
1,196 |
$44K |
| D1110 |
Prophylaxis - adult |
820 |
819 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
208 |
124 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
99 |
27 |
$15K |
| D2950 |
|
70 |
45 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
43 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
204 |
203 |
$2K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$378.00 |
| D9630 |
|
54 |
40 |
$0.00 |