| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,577 |
1,577 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,408 |
1,408 |
$20K |
| D1110 |
Prophylaxis - adult |
416 |
416 |
$18K |
| D1120 |
Prophylaxis - child |
571 |
571 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
132 |
74 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
898 |
898 |
$13K |
| D0274 |
Bitewings - four radiographic images |
236 |
236 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
769 |
742 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
153 |
136 |
$4K |
| D0272 |
Bitewings - two radiographic images |
178 |
178 |
$3K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |