| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
803 |
790 |
$19K |
| D1120 |
Prophylaxis - child |
534 |
523 |
$18K |
| D1206 |
Topical application of fluoride varnish |
912 |
896 |
$18K |
| D1110 |
Prophylaxis - adult |
232 |
231 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
105 |
102 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
53 |
$715.88 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$516.44 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
14 |
$432.88 |