| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,173 |
2,123 |
$48K |
| D1120 |
Prophylaxis - child |
1,223 |
1,205 |
$36K |
| D1110 |
Prophylaxis - adult |
936 |
923 |
$31K |
| D1206 |
Topical application of fluoride varnish |
903 |
892 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
967 |
946 |
$14K |
| D0274 |
Bitewings - four radiographic images |
226 |
222 |
$6K |
| D0272 |
Bitewings - two radiographic images |
274 |
270 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
27 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
24 |
$522.87 |
| D1999 |
|
388 |
375 |
$0.00 |
| D1330 |
|
14 |
14 |
$0.00 |