| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
811 |
804 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
414 |
414 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
219 |
219 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
786 |
778 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,135 |
633 |
$13K |
| D1310 |
|
268 |
268 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
208 |
190 |
$8K |
| D0272 |
Bitewings - two radiographic images |
296 |
296 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
27 |
$3K |
| D9430 |
|
45 |
41 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$1K |
| D0603 |
|
96 |
96 |
$1K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$280.80 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$192.00 |
| D0601 |
|
12 |
12 |
$180.00 |