| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
808 |
808 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,275 |
1,273 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,072 |
1,072 |
$21K |
| D1110 |
Prophylaxis - adult |
408 |
406 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
155 |
135 |
$5K |
| D0274 |
Bitewings - four radiographic images |
167 |
167 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
337 |
335 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
29 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
305 |
252 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$1K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$1K |