| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
335 |
330 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
326 |
324 |
$9K |
| D1206 |
Topical application of fluoride varnish |
377 |
372 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
124 |
108 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
230 |
$3K |
| D0274 |
Bitewings - four radiographic images |
195 |
192 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
226 |
218 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
106 |
105 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$423.84 |
| D0603 |
|
315 |
310 |
$0.00 |
| D0602 |
|
121 |
119 |
$0.00 |