| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,354 |
1,354 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,244 |
1,244 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,649 |
1,649 |
$32K |
| D1110 |
Prophylaxis - adult |
495 |
495 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
238 |
138 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,027 |
1,020 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
313 |
312 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
268 |
221 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
310 |
299 |
$4K |
| D1351 |
Sealant - per tooth |
120 |
41 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$705.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$684.60 |