| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
438 |
419 |
$12K |
| D1120 |
Prophylaxis - child |
246 |
241 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
40 |
$8K |
| D1206 |
Topical application of fluoride varnish |
570 |
551 |
$8K |
| D1110 |
Prophylaxis - adult |
80 |
74 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
119 |
101 |
$3K |
| D0274 |
Bitewings - four radiographic images |
61 |
55 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
108 |
60 |
$978.43 |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
74 |
$816.96 |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$588.00 |
| D0601 |
|
596 |
585 |
$0.00 |
| D0603 |
|
40 |
40 |
$0.00 |