| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
507 |
495 |
$20K |
| D1206 |
Topical application of fluoride varnish |
681 |
671 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
488 |
482 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
180 |
96 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
321 |
290 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
68 |
$8K |
| D0274 |
Bitewings - four radiographic images |
336 |
332 |
$7K |
| D1120 |
Prophylaxis - child |
126 |
125 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$840.30 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
12 |
$292.50 |