| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
470 |
469 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
633 |
632 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
468 |
467 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
218 |
188 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
105 |
105 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
172 |
171 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
150 |
130 |
$2K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$782.75 |
| D0240 |
|
24 |
12 |
$294.48 |