| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,147 |
1,147 |
$62K |
| D7140 |
Extraction, erupted tooth or exposed root |
799 |
520 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
963 |
963 |
$26K |
| D1120 |
Prophylaxis - child |
643 |
641 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
1,051 |
1,039 |
$17K |
| D1206 |
Topical application of fluoride varnish |
536 |
536 |
$14K |
| D0274 |
Bitewings - four radiographic images |
361 |
361 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
796 |
783 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
502 |
501 |
$7K |
| D0330 |
Panoramic radiographic image |
145 |
145 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
24 |
$2K |