| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,102 |
1,098 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
637 |
635 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,124 |
1,120 |
$21K |
| D0272 |
Bitewings - two radiographic images |
622 |
620 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
482 |
480 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
698 |
696 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
52 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
610 |
606 |
$6K |
| D1351 |
Sealant - per tooth |
224 |
79 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
169 |
167 |
$5K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$626.92 |