| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,269 |
2,262 |
$187K |
| D0120 |
Periodic oral evaluation - established patient |
3,106 |
3,096 |
$174K |
| D1120 |
Prophylaxis - child |
1,678 |
1,671 |
$61K |
| D0274 |
Bitewings - four radiographic images |
2,271 |
2,266 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
668 |
668 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,739 |
3,598 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,651 |
1,648 |
$16K |
| D1351 |
Sealant - per tooth |
324 |
64 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
85 |
53 |
$5K |
| D0272 |
Bitewings - two radiographic images |
332 |
332 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
204 |
203 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$624.00 |