| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,657 |
4,657 |
$108K |
| D1110 |
Prophylaxis - adult |
1,608 |
1,608 |
$81K |
| D1120 |
Prophylaxis - child |
1,961 |
1,961 |
$68K |
| D1206 |
Topical application of fluoride varnish |
3,981 |
3,981 |
$65K |
| D0272 |
Bitewings - two radiographic images |
2,619 |
2,619 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
851 |
851 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
229 |
222 |
$7K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$418.00 |