| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
163 |
163 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
60 |
56 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
102 |
102 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
48 |
48 |
$1K |
| D1206 |
Topical application of fluoride varnish |
25 |
24 |
$600.00 |
| D0603 |
|
58 |
58 |
$520.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$459.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$390.00 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$278.00 |
| D0601 |
|
13 |
13 |
$130.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
26 |
$93.00 |