| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,147 |
964 |
$45K |
| D1206 |
Topical application of fluoride varnish |
1,127 |
944 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,087 |
917 |
$21K |
| D0272 |
Bitewings - two radiographic images |
350 |
292 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
26 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
61 |
36 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
14 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
15 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
54 |
40 |
$2K |
| D0240 |
|
34 |
21 |
$1K |
| D0274 |
Bitewings - four radiographic images |
30 |
18 |
$984.00 |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
39 |
$810.00 |