| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
56 |
$6K |
| D1110 |
Prophylaxis - adult |
196 |
171 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
41 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
33 |
$5K |
| D0274 |
Bitewings - four radiographic images |
177 |
157 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
403 |
154 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
88 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
258 |
227 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
108 |
96 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
43 |
$1K |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$374.08 |