| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
311 |
299 |
$9K |
| D1206 |
Topical application of fluoride varnish |
295 |
283 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
62 |
52 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
138 |
135 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
20 |
$592.80 |
| D0603 |
|
43 |
43 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
43 |
$0.00 |