| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
463 |
203 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
777 |
740 |
$30K |
| D1120 |
Prophylaxis - child |
929 |
891 |
$25K |
| D1206 |
Topical application of fluoride varnish |
684 |
662 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
55 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
284 |
265 |
$10K |
| D0272 |
Bitewings - two radiographic images |
388 |
378 |
$7K |
| D0274 |
Bitewings - four radiographic images |
188 |
176 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
181 |
168 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
19 |
18 |
$478.34 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
14 |
$222.18 |