| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
928 |
905 |
$22K |
| D1110 |
Prophylaxis - adult |
365 |
364 |
$15K |
| D1206 |
Topical application of fluoride varnish |
521 |
517 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
315 |
304 |
$6K |
| D1120 |
Prophylaxis - child |
152 |
151 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$896.79 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
24 |
$780.92 |
| D0272 |
Bitewings - two radiographic images |
25 |
24 |
$396.90 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$380.25 |