| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,611 |
1,552 |
$43K |
| D1120 |
Prophylaxis - child |
1,136 |
1,101 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
267 |
191 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,712 |
1,657 |
$24K |
| D1110 |
Prophylaxis - adult |
368 |
353 |
$18K |
| D0274 |
Bitewings - four radiographic images |
226 |
207 |
$6K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$822.76 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$325.32 |
| D1330 |
|
13 |
12 |
$120.06 |
| D0603 |
|
2,219 |
2,119 |
$0.00 |