| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
914 |
852 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,336 |
1,242 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,256 |
1,169 |
$22K |
| D0274 |
Bitewings - four radiographic images |
284 |
269 |
$8K |
| D1120 |
Prophylaxis - child |
173 |
160 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
13 |
$939.25 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
12 |
$444.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
13 |
$432.06 |