| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
587 |
586 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
679 |
678 |
$16K |
| D1206 |
Topical application of fluoride varnish |
767 |
766 |
$14K |
| D0272 |
Bitewings - two radiographic images |
300 |
299 |
$5K |
| D1110 |
Prophylaxis - adult |
92 |
92 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
75 |
$2K |
| D1330 |
|
341 |
340 |
$2K |
| D0603 |
|
162 |
161 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
39 |
39 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$965.00 |
| D0602 |
|
70 |
70 |
$690.00 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$152.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$128.40 |