| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
946 |
716 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
477 |
181 |
$26K |
| D0330 |
Panoramic radiographic image |
555 |
478 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
919 |
700 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
233 |
90 |
$13K |
| D0274 |
Bitewings - four radiographic images |
652 |
528 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
400 |
348 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
630 |
462 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
431 |
300 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
53 |
$6K |
| D1120 |
Prophylaxis - child |
136 |
99 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
112 |
73 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
123 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
210 |
146 |
$1K |