| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
674 |
668 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
738 |
732 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
233 |
231 |
$7K |
| D0274 |
Bitewings - four radiographic images |
180 |
178 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
64 |
$4K |
| D1120 |
Prophylaxis - child |
83 |
83 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
197 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
28 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
18 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
19 |
$2K |
| D1351 |
Sealant - per tooth |
29 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$624.00 |
| D9110 |
|
13 |
12 |
$597.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$352.00 |