| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
706 |
706 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
850 |
850 |
$21K |
| D1110 |
Prophylaxis - adult |
244 |
244 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
649 |
649 |
$9K |
| D0272 |
Bitewings - two radiographic images |
259 |
259 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
43 |
$3K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$960.65 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$794.00 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$348.60 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$231.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$164.95 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
34 |
33 |
$0.00 |
| D1330 |
|
410 |
410 |
$0.00 |