| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,058 |
1,057 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
502 |
502 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,949 |
1,295 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
272 |
$18K |
| D0350 |
|
1,831 |
544 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,112 |
1,111 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
181 |
180 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
183 |
171 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
49 |
$5K |
| D1110 |
Prophylaxis - adult |
55 |
55 |
$5K |
| D1320 |
|
261 |
260 |
$4K |
| D0274 |
Bitewings - four radiographic images |
108 |
108 |
$2K |
| D1999 |
|
949 |
895 |
$630.00 |
| D0272 |
Bitewings - two radiographic images |
51 |
51 |
$600.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$480.00 |