| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
94 |
94 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
141 |
138 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
135 |
135 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
68 |
68 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
16 |
$1K |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$602.25 |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$330.00 |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
60 |
$300.00 |
| D0603 |
|
16 |
16 |
$160.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
17 |
$69.00 |