| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
510 |
491 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,013 |
968 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
239 |
95 |
$18K |
| D1120 |
Prophylaxis - child |
431 |
392 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
204 |
185 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
42 |
$6K |
| D1206 |
Topical application of fluoride varnish |
262 |
242 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
29 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
76 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
101 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
90 |
$2K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$529.10 |