| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
749 |
747 |
$28K |
| D1206 |
Topical application of fluoride varnish |
993 |
991 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
800 |
800 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
254 |
252 |
$14K |
| D0274 |
Bitewings - four radiographic images |
285 |
285 |
$9K |
| D1110 |
Prophylaxis - adult |
147 |
147 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
163 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
42 |
$4K |
| D0240 |
|
176 |
96 |
$2K |
| D0272 |
Bitewings - two radiographic images |
107 |
107 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
117 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$848.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
92 |
44 |
$567.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$533.00 |