| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
721 |
665 |
$22K |
| D1351 |
Sealant - per tooth |
282 |
76 |
$15K |
| D0274 |
Bitewings - four radiographic images |
578 |
539 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
531 |
482 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
94 |
60 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
381 |
353 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
814 |
720 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
691 |
593 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
201 |
173 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
48 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
223 |
211 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
88 |
74 |
$3K |
| D1120 |
Prophylaxis - child |
76 |
72 |
$2K |
| D1354 |
|
67 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
44 |
42 |
$1K |
| D1330 |
|
94 |
91 |
$622.40 |
| D1310 |
|
56 |
53 |
$411.75 |