| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
418 |
394 |
$28K |
| D1120 |
Prophylaxis - child |
445 |
425 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
339 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
267 |
104 |
$17K |
| D1206 |
Topical application of fluoride varnish |
373 |
350 |
$6K |
| D9430 |
|
104 |
99 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
637 |
212 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
135 |
131 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$709.80 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$583.20 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$520.00 |
| D1999 |
|
15 |
14 |
$0.00 |