| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
403 |
400 |
$14K |
| D0274 |
Bitewings - four radiographic images |
355 |
352 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
422 |
421 |
$8K |
| D0330 |
Panoramic radiographic image |
180 |
179 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
47 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
198 |
196 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
25 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
45 |
$4K |
| D1351 |
Sealant - per tooth |
99 |
16 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
80 |
80 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
151 |
$1K |
| D1120 |
Prophylaxis - child |
19 |
19 |
$570.00 |