| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
655 |
655 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
639 |
639 |
$20K |
| D1206 |
Topical application of fluoride varnish |
261 |
259 |
$9K |
| D0272 |
Bitewings - two radiographic images |
491 |
490 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
439 |
439 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
503 |
500 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
580 |
577 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$342.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
74 |
70 |
$0.00 |
| D1330 |
|
454 |
454 |
$0.00 |
| D0603 |
|
312 |
312 |
$0.00 |