| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
469 |
469 |
$11K |
| D1110 |
Prophylaxis - adult |
213 |
213 |
$10K |
| D1120 |
Prophylaxis - child |
270 |
270 |
$10K |
| D1206 |
Topical application of fluoride varnish |
412 |
412 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
152 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
34 |
$5K |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
44 |
36 |
$2K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$1K |