| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,297 |
2,292 |
$103K |
| D1120 |
Prophylaxis - child |
2,157 |
2,153 |
$97K |
| D1206 |
Topical application of fluoride varnish |
2,341 |
2,337 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
487 |
290 |
$53K |
| D0272 |
Bitewings - two radiographic images |
688 |
688 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
753 |
690 |
$19K |
| D9920 |
|
168 |
143 |
$15K |
| D0603 |
|
697 |
695 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
268 |
264 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
13 |
$4K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$1K |
| D0240 |
|
16 |
16 |
$288.00 |