| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
175 |
172 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
27 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
184 |
181 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
192 |
190 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
130 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
63 |
$2K |
| D0272 |
Bitewings - two radiographic images |
51 |
49 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
25 |
$918.25 |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$912.19 |