| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
961 |
953 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,281 |
1,274 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,376 |
1,365 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
25 |
$6K |
| D0272 |
Bitewings - two radiographic images |
231 |
228 |
$5K |
| D1110 |
Prophylaxis - adult |
27 |
26 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
20 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
34 |
$989.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$530.00 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
27 |
$420.00 |