| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,131 |
1,131 |
$27K |
| D1120 |
Prophylaxis - child |
575 |
573 |
$22K |
| D1110 |
Prophylaxis - adult |
483 |
483 |
$19K |
| D1206 |
Topical application of fluoride varnish |
484 |
483 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
136 |
136 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
16 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
52 |
52 |
$705.75 |