| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,926 |
1,905 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,783 |
1,763 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,801 |
1,784 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
127 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
294 |
294 |
$8K |
| D0272 |
Bitewings - two radiographic images |
499 |
491 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
198 |
198 |
$3K |
| D1351 |
Sealant - per tooth |
82 |
27 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$2K |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
24 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$511.95 |