| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
110 |
108 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
165 |
164 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
16 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
33 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
116 |
116 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$1K |
| D1120 |
Prophylaxis - child |
48 |
48 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
16 |
$1K |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$587.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
15 |
$360.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$348.00 |