| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,015 |
1,015 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
443 |
443 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
291 |
291 |
$19K |
| D1206 |
Topical application of fluoride varnish |
918 |
918 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,661 |
1,021 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
335 |
302 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
107 |
$10K |
| D0274 |
Bitewings - four radiographic images |
168 |
168 |
$4K |
| D0272 |
Bitewings - two radiographic images |
183 |
183 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$928.20 |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
59 |
$694.00 |