| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
639 |
632 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
285 |
123 |
$37K |
| D2750 |
|
64 |
55 |
$31K |
| D0330 |
Panoramic radiographic image |
636 |
625 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
453 |
452 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
575 |
570 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
240 |
224 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
780 |
752 |
$9K |
| D0274 |
Bitewings - four radiographic images |
285 |
280 |
$7K |
| D1206 |
Topical application of fluoride varnish |
169 |
169 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
299 |
292 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$276.00 |