| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
186 |
176 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
22 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
186 |
175 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
110 |
100 |
$3K |
| D0274 |
Bitewings - four radiographic images |
82 |
79 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
37 |
36 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$409.20 |