| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
473 |
473 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
574 |
574 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
496 |
496 |
$1K |
| D9994 |
|
655 |
655 |
$774.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
241 |
213 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
127 |
127 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
124 |
118 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
237 |
237 |
$0.00 |
| D1110 |
Prophylaxis - adult |
59 |
59 |
$0.00 |
| D1354 |
|
39 |
12 |
$0.00 |