| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,494 |
1,467 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
2,000 |
1,973 |
$61K |
| D1351 |
Sealant - per tooth |
1,740 |
321 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,500 |
2,465 |
$58K |
| D1120 |
Prophylaxis - child |
1,065 |
1,052 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
544 |
531 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
125 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
407 |
396 |
$19K |
| D0274 |
Bitewings - four radiographic images |
433 |
427 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
756 |
731 |
$8K |
| D0330 |
Panoramic radiographic image |
184 |
176 |
$8K |
| D0272 |
Bitewings - two radiographic images |
340 |
335 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
12 |
$3K |
| D1330 |
|
410 |
402 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$2K |