| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
518 |
511 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
923 |
913 |
$20K |
| D1120 |
Prophylaxis - child |
541 |
533 |
$15K |
| D1206 |
Topical application of fluoride varnish |
902 |
887 |
$14K |
| D0272 |
Bitewings - two radiographic images |
634 |
619 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
107 |
44 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
14 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
80 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
34 |
29 |
$657.93 |
| D9996 |
|
259 |
259 |
$0.00 |