| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
299 |
290 |
$11K |
| D1351 |
Sealant - per tooth |
300 |
50 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
326 |
313 |
$7K |
| D0274 |
Bitewings - four radiographic images |
222 |
211 |
$6K |
| D0330 |
Panoramic radiographic image |
132 |
129 |
$5K |
| D1120 |
Prophylaxis - child |
159 |
153 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
259 |
250 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
150 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
60 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
31 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
112 |
$997.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
84 |
78 |
$676.80 |