| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
998 |
998 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
2,131 |
2,131 |
$45K |
| D1120 |
Prophylaxis - child |
1,429 |
1,429 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,789 |
1,789 |
$27K |
| D0272 |
Bitewings - two radiographic images |
846 |
846 |
$15K |
| D0330 |
Panoramic radiographic image |
271 |
271 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
50 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
122 |
61 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
264 |
264 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
244 |
243 |
$7K |
| D1206 |
Topical application of fluoride varnish |
295 |
295 |
$5K |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$2K |
| D1351 |
Sealant - per tooth |
64 |
17 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
27 |
$426.72 |