| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,484 |
2,471 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
3,006 |
2,988 |
$58K |
| D1351 |
Sealant - per tooth |
1,582 |
342 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,112 |
1,103 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,057 |
1,051 |
$19K |
| D0330 |
Panoramic radiographic image |
501 |
495 |
$18K |
| D1120 |
Prophylaxis - child |
555 |
552 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
302 |
211 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
173 |
75 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
180 |
139 |
$10K |
| D0272 |
Bitewings - two radiographic images |
243 |
242 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
164 |
162 |
$3K |
| D2335 |
|
21 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$108.00 |