| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
160 |
91 |
$13K |
| D1110 |
Prophylaxis - adult |
226 |
218 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
240 |
234 |
$7K |
| D1120 |
Prophylaxis - child |
197 |
193 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
286 |
279 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
434 |
422 |
$7K |
| D0274 |
Bitewings - four radiographic images |
250 |
242 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
154 |
$6K |
| D0330 |
Panoramic radiographic image |
127 |
123 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
307 |
262 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
14 |
$113.50 |