| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
564 |
563 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
670 |
670 |
$13K |
| D0274 |
Bitewings - four radiographic images |
346 |
345 |
$9K |
| D1351 |
Sealant - per tooth |
362 |
61 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
517 |
507 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
256 |
255 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
198 |
197 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
79 |
45 |
$4K |
| D1120 |
Prophylaxis - child |
149 |
148 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
404 |
403 |
$3K |
| D9110 |
|
37 |
37 |
$1K |
| D1330 |
|
13 |
13 |
$60.00 |