| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
948 |
896 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
871 |
824 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
775 |
729 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
239 |
183 |
$5K |
| D1351 |
Sealant - per tooth |
180 |
54 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
91 |
79 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$879.87 |