| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,429 |
2,428 |
$90K |
| D1206 |
Topical application of fluoride varnish |
2,543 |
2,542 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,094 |
2,094 |
$52K |
| D1110 |
Prophylaxis - adult |
168 |
168 |
$9K |
| D0272 |
Bitewings - two radiographic images |
303 |
303 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
423 |
421 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
134 |
134 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
85 |
85 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
16 |
$489.76 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$449.97 |