| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,736 |
1,736 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
3,297 |
3,297 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
746 |
435 |
$74K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,173 |
3,173 |
$52K |
| D0272 |
Bitewings - two radiographic images |
2,428 |
2,428 |
$45K |
| D1120 |
Prophylaxis - child |
1,245 |
1,245 |
$43K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,112 |
1,057 |
$36K |
| D7240 |
Removal of impacted tooth - completely bony |
111 |
30 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
79 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
62 |
54 |
$8K |
| D0330 |
Panoramic radiographic image |
138 |
138 |
$6K |
| D0274 |
Bitewings - four radiographic images |
152 |
152 |
$5K |
| D9243 |
|
43 |
43 |
$3K |
| D9239 |
|
43 |
43 |
$3K |