| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
144 |
144 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
190 |
190 |
$4K |
| D1206 |
Topical application of fluoride varnish |
93 |
93 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
458 |
449 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
198 |
198 |
$648.00 |
| D0272 |
Bitewings - two radiographic images |
58 |
58 |
$540.00 |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$485.00 |
| D0603 |
|
33 |
33 |
$330.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$290.00 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$264.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$48.00 |