| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,830 |
1,830 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
1,174 |
1,174 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,437 |
1,437 |
$18K |
| D1351 |
Sealant - per tooth |
595 |
200 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
433 |
$11K |
| D1206 |
Topical application of fluoride varnish |
438 |
438 |
$10K |
| D0272 |
Bitewings - two radiographic images |
628 |
628 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
823 |
820 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
737 |
728 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
44 |
37 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
17 |
$376.25 |