| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,298 |
1,291 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
178 |
102 |
$13K |
| D1110 |
Prophylaxis - adult |
370 |
370 |
$11K |
| D1120 |
Prophylaxis - child |
364 |
362 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
319 |
315 |
$6K |
| D1206 |
Topical application of fluoride varnish |
134 |
133 |
$3K |
| D1999 |
|
304 |
296 |
$3K |
| D0272 |
Bitewings - two radiographic images |
174 |
173 |
$2K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$657.21 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
15 |
$407.82 |
| D9997 |
|
18 |
18 |
$0.00 |