| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
926 |
894 |
$35K |
| D1120 |
Prophylaxis - child |
1,170 |
1,152 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,935 |
1,887 |
$33K |
| D9630 |
|
1,860 |
1,809 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,757 |
1,720 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
296 |
163 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,524 |
1,235 |
$13K |
| D9920 |
|
187 |
179 |
$12K |
| D0274 |
Bitewings - four radiographic images |
497 |
488 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
393 |
346 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
931 |
749 |
$8K |
| D1351 |
Sealant - per tooth |
56 |
17 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
24 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
71 |
71 |
$806.00 |
| D0240 |
|
32 |
16 |
$0.00 |