| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
130 |
130 |
$2K |
| D1206 |
Topical application of fluoride varnish |
194 |
194 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
167 |
167 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$920.25 |
| D9994 |
|
201 |
201 |
$699.40 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
41 |
39 |
$526.32 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$394.68 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$0.00 |