| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
75 |
63 |
$2K |
| D1206 |
Topical application of fluoride varnish |
75 |
63 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
42 |
31 |
$867.68 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$598.32 |
| D0274 |
Bitewings - four radiographic images |
36 |
29 |
$589.25 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$553.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
131 |
60 |
$518.32 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
24 |
23 |
$295.04 |
| D0272 |
Bitewings - two radiographic images |
27 |
25 |
$286.35 |
| D0220 |
Intraoral - periapical first radiographic image |
23 |
22 |
$254.55 |