| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
662 |
662 |
$30K |
| D1206 |
Topical application of fluoride varnish |
674 |
674 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
508 |
508 |
$13K |
| D0272 |
Bitewings - two radiographic images |
317 |
317 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
24 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
46 |
46 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
63 |
$523.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
44 |
$175.00 |