| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,535 |
3,337 |
$69K |
| D1206 |
Topical application of fluoride varnish |
3,459 |
3,256 |
$64K |
| D1110 |
Prophylaxis - adult |
1,535 |
1,435 |
$63K |
| D1120 |
Prophylaxis - child |
1,854 |
1,747 |
$52K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
498 |
424 |
$11K |
| D0274 |
Bitewings - four radiographic images |
130 |
122 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
59 |
57 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
15 |
$856.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$426.00 |