| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
470 |
197 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
804 |
742 |
$30K |
| D1120 |
Prophylaxis - child |
956 |
881 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
85 |
$17K |
| D1206 |
Topical application of fluoride varnish |
647 |
600 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
265 |
250 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
34 |
$8K |
| D0272 |
Bitewings - two radiographic images |
326 |
310 |
$6K |
| D0274 |
Bitewings - four radiographic images |
177 |
161 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
204 |
194 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$409.24 |