| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
529 |
529 |
$27K |
| D1206 |
Topical application of fluoride varnish |
568 |
568 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
671 |
671 |
$19K |
| D1110 |
Prophylaxis - adult |
109 |
109 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
176 |
172 |
$1K |
| D0274 |
Bitewings - four radiographic images |
70 |
70 |
$966.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$920.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
26 |
$805.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$782.00 |
| D0601 |
|
57 |
57 |
$570.00 |
| D0602 |
|
52 |
52 |
$520.00 |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$460.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
91 |
91 |
$345.00 |