| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
528 |
494 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
250 |
83 |
$9K |
| D1110 |
Prophylaxis - adult |
185 |
166 |
$6K |
| D0274 |
Bitewings - four radiographic images |
291 |
272 |
$6K |
| D0330 |
Panoramic radiographic image |
124 |
119 |
$4K |
| D1120 |
Prophylaxis - child |
62 |
55 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
57 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
144 |
$835.66 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$683.06 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
14 |
$203.85 |