| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
401 |
401 |
$13K |
| D0274 |
Bitewings - four radiographic images |
399 |
398 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
451 |
451 |
$9K |
| D1351 |
Sealant - per tooth |
275 |
61 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
104 |
36 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
266 |
266 |
$4K |
| D1120 |
Prophylaxis - child |
167 |
167 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
150 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
207 |
$2K |
| D0272 |
Bitewings - two radiographic images |
54 |
54 |
$841.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
74 |
63 |
$474.92 |