| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
381 |
381 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
337 |
337 |
$14K |
| D9999 |
Unspecified adjunctive procedure, by report |
63 |
63 |
$13K |
| D1206 |
Topical application of fluoride varnish |
400 |
400 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
71 |
71 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
30 |
$651.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$632.00 |
| D0603 |
|
13 |
13 |
$130.00 |