| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
458 |
413 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
225 |
95 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
605 |
568 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
373 |
336 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
136 |
63 |
$10K |
| D1206 |
Topical application of fluoride varnish |
495 |
458 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
102 |
90 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
119 |
69 |
$7K |
| D1120 |
Prophylaxis - child |
226 |
195 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
84 |
$3K |
| D0274 |
Bitewings - four radiographic images |
94 |
88 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
80 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
19 |
13 |
$380.69 |