| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
428 |
426 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
274 |
273 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
102 |
38 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
398 |
395 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
37 |
$9K |
| D0274 |
Bitewings - four radiographic images |
212 |
210 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
185 |
182 |
$6K |
| D4910 |
|
62 |
62 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
342 |
336 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
48 |
47 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
166 |
163 |
$2K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$418.22 |