| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,552 |
2,216 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,480 |
2,175 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,306 |
1,200 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
958 |
756 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
276 |
137 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
695 |
411 |
$18K |
| D0330 |
Panoramic radiographic image |
146 |
135 |
$7K |
| D0272 |
Bitewings - two radiographic images |
159 |
99 |
$2K |
| D1351 |
Sealant - per tooth |
48 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
29 |
25 |
$882.26 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
16 |
$647.24 |