| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,497 |
2,483 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
3,178 |
3,158 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
526 |
309 |
$29K |
| D1206 |
Topical application of fluoride varnish |
691 |
682 |
$12K |
| D0274 |
Bitewings - four radiographic images |
427 |
421 |
$11K |
| D1120 |
Prophylaxis - child |
352 |
352 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
126 |
80 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
163 |
130 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
48 |
$3K |
| D2331 |
|
45 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
159 |
158 |
$2K |
| D9110 |
|
70 |
69 |
$2K |
| D2332 |
|
18 |
15 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
25 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$592.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$478.70 |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
56 |
$428.10 |
| D1999 |
|
257 |
253 |
$84.00 |