| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
120 |
120 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
110 |
110 |
$3K |
| D1206 |
Topical application of fluoride varnish |
149 |
149 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$1K |
| D1110 |
Prophylaxis - adult |
23 |
23 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
29 |
$975.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$701.26 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$648.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
18 |
18 |
$648.00 |
| D0220 |
Intraoral - periapical first radiographic image |
20 |
20 |
$243.77 |