| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,531 |
2,510 |
$63K |
| D1110 |
Prophylaxis - adult |
1,558 |
1,544 |
$60K |
| D7140 |
Extraction, erupted tooth or exposed root |
847 |
411 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
1,284 |
1,235 |
$44K |
| D1120 |
Prophylaxis - child |
905 |
899 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
313 |
158 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
93 |
$14K |
| D0272 |
Bitewings - two radiographic images |
38 |
37 |
$719.88 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$177.18 |