| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
55 |
55 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
65 |
64 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
37 |
30 |
$1K |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$816.17 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
37 |
$731.49 |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$681.41 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$633.11 |
| D0272 |
Bitewings - two radiographic images |
23 |
23 |
$492.89 |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
18 |
$264.42 |