| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
482 |
133 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
299 |
$6K |
| D0330 |
Panoramic radiographic image |
142 |
142 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
21 |
21 |
$336.00 |