| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
505 |
505 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,055 |
1,055 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
249 |
97 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
657 |
657 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
270 |
227 |
$7K |
| D1120 |
Prophylaxis - child |
240 |
240 |
$7K |
| D0274 |
Bitewings - four radiographic images |
97 |
97 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
96 |
96 |
$1K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$236.88 |