| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,528 |
2,033 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
4,187 |
3,402 |
$99K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,493 |
2,787 |
$70K |
| D1120 |
Prophylaxis - child |
1,704 |
1,384 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
451 |
295 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,009 |
801 |
$36K |
| D0330 |
Panoramic radiographic image |
504 |
380 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
292 |
180 |
$23K |
| D0272 |
Bitewings - two radiographic images |
663 |
531 |
$16K |
| D1351 |
Sealant - per tooth |
239 |
27 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
76 |
64 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
63 |
$2K |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$550.00 |
| D1999 |
|
174 |
94 |
$0.00 |