| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
820 |
695 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
605 |
282 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
1,253 |
1,035 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,160 |
958 |
$11K |
| D0274 |
Bitewings - four radiographic images |
752 |
628 |
$11K |
| D1120 |
Prophylaxis - child |
604 |
476 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
389 |
303 |
$3K |
| D0330 |
Panoramic radiographic image |
135 |
117 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
74 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
27 |
$499.50 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
13 |
$26.50 |