| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
490 |
490 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
554 |
554 |
$16K |
| D1206 |
Topical application of fluoride varnish |
538 |
538 |
$10K |
| D1110 |
Prophylaxis - adult |
97 |
97 |
$5K |
| D0274 |
Bitewings - four radiographic images |
90 |
90 |
$2K |
| D0272 |
Bitewings - two radiographic images |
146 |
145 |
$2K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
19 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$810.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$574.00 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
30 |
$406.00 |
| D1354 |
|
53 |
12 |
$255.00 |
| D0240 |
|
12 |
12 |
$204.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$196.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
16 |
$0.00 |