| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,635 |
1,622 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,705 |
1,690 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,183 |
1,171 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
186 |
184 |
$5K |
| D0272 |
Bitewings - two radiographic images |
468 |
465 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
15 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
66 |
57 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
103 |
$515.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
27 |
$175.00 |