| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
139 |
130 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
147 |
140 |
$2K |
| D0330 |
Panoramic radiographic image |
52 |
48 |
$2K |
| D0274 |
Bitewings - four radiographic images |
91 |
85 |
$2K |
| D1351 |
Sealant - per tooth |
76 |
15 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
88 |
82 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
41 |
$1K |
| D1120 |
Prophylaxis - child |
47 |
45 |
$962.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
22 |
$250.00 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
14 |
$87.75 |