| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
563 |
563 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
501 |
501 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
520 |
517 |
$9K |
| D0272 |
Bitewings - two radiographic images |
145 |
143 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$911.43 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
28 |
$837.17 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$465.03 |