| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
916 |
870 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,132 |
1,080 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
474 |
229 |
$18K |
| D1120 |
Prophylaxis - child |
820 |
789 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
858 |
825 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
1,162 |
1,106 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,224 |
1,174 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,846 |
1,751 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,358 |
1,541 |
$11K |
| D0272 |
Bitewings - two radiographic images |
545 |
525 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
68 |
$5K |
| D1351 |
Sealant - per tooth |
236 |
54 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
188 |
185 |
$3K |
| D0330 |
Panoramic radiographic image |
76 |
73 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$903.33 |