| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
566 |
566 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
825 |
816 |
$23K |
| D1206 |
Topical application of fluoride varnish |
830 |
821 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
210 |
208 |
$12K |
| D1110 |
Prophylaxis - adult |
211 |
208 |
$11K |
| D0272 |
Bitewings - two radiographic images |
265 |
265 |
$8K |
| D1330 |
|
567 |
567 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
39 |
$4K |
| D0274 |
Bitewings - four radiographic images |
93 |
93 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
63 |
$629.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$555.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$134.00 |