| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,220 |
1,209 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,941 |
1,930 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,445 |
1,438 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
558 |
249 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
702 |
691 |
$24K |
| D0330 |
Panoramic radiographic image |
463 |
455 |
$23K |
| D1120 |
Prophylaxis - child |
631 |
628 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
371 |
361 |
$10K |
| D0274 |
Bitewings - four radiographic images |
357 |
356 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
106 |
70 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
46 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
490 |
462 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
14 |
$550.41 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
28 |
$287.76 |