| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
742 |
739 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
778 |
776 |
$19K |
| D1206 |
Topical application of fluoride varnish |
852 |
849 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
174 |
166 |
$9K |
| D0274 |
Bitewings - four radiographic images |
226 |
225 |
$6K |
| D1110 |
Prophylaxis - adult |
109 |
109 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
34 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
117 |
$3K |
| D0272 |
Bitewings - two radiographic images |
120 |
118 |
$2K |
| D0240 |
|
215 |
108 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
187 |
184 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
265 |
85 |
$1K |
| D1330 |
|
50 |
50 |
$500.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$405.00 |