| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,726 |
1,712 |
$94K |
| D1120 |
Prophylaxis - child |
1,553 |
1,553 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,077 |
2,077 |
$60K |
| D1206 |
Topical application of fluoride varnish |
1,768 |
1,768 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
780 |
780 |
$34K |
| D1351 |
Sealant - per tooth |
984 |
299 |
$31K |
| D0274 |
Bitewings - four radiographic images |
813 |
813 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
270 |
167 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
185 |
138 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
378 |
378 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
638 |
638 |
$15K |
| D0272 |
Bitewings - two radiographic images |
479 |
479 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
81 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
25 |
$960.70 |