| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
644 |
644 |
$24K |
| D1206 |
Topical application of fluoride varnish |
699 |
692 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
513 |
513 |
$13K |
| D0274 |
Bitewings - four radiographic images |
271 |
271 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
147 |
147 |
$3K |
| D1110 |
Prophylaxis - adult |
51 |
51 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
16 |
$2K |
| D0240 |
|
143 |
69 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
20 |
20 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$572.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$126.00 |