| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
110 |
110 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
12 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
134 |
134 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
142 |
142 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
43 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$507.48 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$338.40 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$219.96 |