| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,236 |
1,200 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,287 |
1,257 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,387 |
1,344 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
175 |
88 |
$7K |
| D0272 |
Bitewings - two radiographic images |
597 |
577 |
$6K |
| D1351 |
Sealant - per tooth |
150 |
41 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
41 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$2K |
| D1110 |
Prophylaxis - adult |
41 |
40 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
70 |
56 |
$1K |
| D0274 |
Bitewings - four radiographic images |
60 |
59 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
14 |
$342.55 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$225.80 |