| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
868 |
799 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
413 |
136 |
$20K |
| D0330 |
Panoramic radiographic image |
468 |
411 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
639 |
572 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
785 |
735 |
$12K |
| D0274 |
Bitewings - four radiographic images |
548 |
524 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
402 |
367 |
$6K |
| D1120 |
Prophylaxis - child |
237 |
216 |
$4K |
| D1351 |
Sealant - per tooth |
61 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
249 |
231 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
15 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
40 |
$435.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$110.00 |