| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,051 |
1,051 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,215 |
1,215 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,265 |
1,265 |
$15K |
| D0272 |
Bitewings - two radiographic images |
450 |
450 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
15 |
$2K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$269.28 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$198.93 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$89.08 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
40 |
37 |
$0.00 |