| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
543 |
543 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
994 |
993 |
$27K |
| D1120 |
Prophylaxis - child |
652 |
652 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
185 |
125 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
946 |
946 |
$21K |
| D1351 |
Sealant - per tooth |
675 |
197 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
846 |
832 |
$14K |
| D0274 |
Bitewings - four radiographic images |
331 |
330 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,059 |
793 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$4K |
| D0272 |
Bitewings - two radiographic images |
118 |
118 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$934.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$632.00 |