| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,015 |
1,012 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,635 |
1,630 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
344 |
182 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,266 |
1,262 |
$39K |
| D1120 |
Prophylaxis - child |
554 |
552 |
$30K |
| D0274 |
Bitewings - four radiographic images |
447 |
447 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
247 |
224 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
26 |
$10K |
| D0272 |
Bitewings - two radiographic images |
325 |
325 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
27 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
67 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$288.00 |