| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
612 |
611 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
597 |
597 |
$14K |
| D1206 |
Topical application of fluoride varnish |
373 |
372 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
167 |
167 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
86 |
78 |
$4K |
| D0272 |
Bitewings - two radiographic images |
159 |
158 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$943.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
28 |
$806.00 |
| D0603 |
|
68 |
68 |
$680.00 |
| D1330 |
|
127 |
127 |
$620.00 |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
70 |
$350.00 |
| D0602 |
|
12 |
12 |
$120.00 |