| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,464 |
1,456 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,872 |
1,864 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,456 |
1,450 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
293 |
268 |
$6K |
| D0272 |
Bitewings - two radiographic images |
307 |
306 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
385 |
384 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
315 |
310 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$1K |
| D0240 |
|
95 |
50 |
$622.05 |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$0.00 |
| D3120 |
|
103 |
43 |
$0.00 |