| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
457 |
457 |
$15K |
| D0274 |
Bitewings - four radiographic images |
367 |
366 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
426 |
426 |
$8K |
| D1351 |
Sealant - per tooth |
318 |
50 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
73 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
300 |
300 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
127 |
127 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
255 |
255 |
$4K |
| D1120 |
Prophylaxis - child |
183 |
183 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
68 |
42 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
346 |
342 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
331 |
239 |
$2K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$231.76 |