| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
332 |
332 |
$12K |
| D1206 |
Topical application of fluoride varnish |
448 |
448 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
412 |
412 |
$10K |
| D1110 |
Prophylaxis - adult |
148 |
148 |
$6K |
| D1330 |
|
412 |
412 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
83 |
82 |
$4K |
| D0274 |
Bitewings - four radiographic images |
148 |
148 |
$4K |
| D0330 |
Panoramic radiographic image |
87 |
87 |
$3K |
| D0272 |
Bitewings - two radiographic images |
126 |
126 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
45 |
$1K |
| D0240 |
|
45 |
24 |
$544.20 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$124.40 |