| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
408 |
407 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
297 |
297 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
97 |
24 |
$13K |
| D1206 |
Topical application of fluoride varnish |
344 |
344 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
38 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
241 |
240 |
$8K |
| D0274 |
Bitewings - four radiographic images |
179 |
179 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
59 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$153.66 |