| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,061 |
1,061 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
738 |
738 |
$15K |
| D1110 |
Prophylaxis - adult |
312 |
312 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
592 |
586 |
$9K |
| D1120 |
Prophylaxis - child |
234 |
234 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
39 |
$6K |
| D0274 |
Bitewings - four radiographic images |
114 |
114 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
389 |
373 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
36 |
27 |
$940.68 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$496.48 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$488.04 |