| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
419 |
419 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
453 |
453 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
427 |
427 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
94 |
93 |
$5K |
| D0274 |
Bitewings - four radiographic images |
104 |
104 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$920.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$725.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$540.00 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
48 |
$470.00 |
| D0240 |
|
22 |
16 |
$300.00 |