| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
226 |
226 |
$7K |
| D1206 |
Topical application of fluoride varnish |
224 |
223 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
185 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
141 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
41 |
41 |
$926.25 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$399.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
13 |
$0.00 |