| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
848 |
848 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,375 |
1,375 |
$32K |
| D0274 |
Bitewings - four radiographic images |
893 |
893 |
$24K |
| D1120 |
Prophylaxis - child |
518 |
518 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
750 |
750 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
114 |
69 |
$12K |
| D1206 |
Topical application of fluoride varnish |
582 |
582 |
$9K |
| D0330 |
Panoramic radiographic image |
76 |
76 |
$4K |
| D1351 |
Sealant - per tooth |
117 |
41 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$3K |
| D0272 |
Bitewings - two radiographic images |
124 |
124 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$390.00 |