| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
656 |
651 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
194 |
102 |
$15K |
| D1120 |
Prophylaxis - child |
325 |
322 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
793 |
785 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
860 |
843 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
936 |
762 |
$10K |
| D0272 |
Bitewings - two radiographic images |
146 |
146 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
27 |
$3K |
| D1110 |
Prophylaxis - adult |
32 |
31 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$866.64 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
25 |
$650.64 |
| D0603 |
|
767 |
762 |
$0.00 |