| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
2,921 |
2,846 |
$60K |
| D1110 |
Prophylaxis - adult |
1,413 |
1,371 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,339 |
2,282 |
$57K |
| D1120 |
Prophylaxis - child |
1,592 |
1,550 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
688 |
429 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,174 |
1,138 |
$29K |
| D0330 |
Panoramic radiographic image |
547 |
540 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
704 |
677 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
179 |
135 |
$11K |
| D0272 |
Bitewings - two radiographic images |
459 |
438 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
102 |
48 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
189 |
174 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
24 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
63 |
61 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
47 |
$550.83 |