| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
103 |
86 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
103 |
97 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
145 |
130 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
118 |
80 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
97 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$375.38 |
| D0272 |
Bitewings - two radiographic images |
19 |
15 |
$348.36 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
12 |
$211.92 |
| D0601 |
|
104 |
94 |
$0.00 |