| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,534 |
1,500 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
2,259 |
2,227 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,907 |
1,888 |
$36K |
| D9630 |
|
1,766 |
1,749 |
$34K |
| D1120 |
Prophylaxis - child |
1,041 |
1,036 |
$32K |
| D0274 |
Bitewings - four radiographic images |
802 |
793 |
$20K |
| D0330 |
Panoramic radiographic image |
546 |
365 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
136 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
87 |
71 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
59 |
59 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
26 |
$645.58 |
| D1999 |
|
249 |
221 |
$0.00 |