| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
51 |
51 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
74 |
74 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
19 |
$2K |
| D1120 |
Prophylaxis - child |
48 |
48 |
$2K |
| D1206 |
Topical application of fluoride varnish |
99 |
99 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
48 |
48 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
19 |
$769.50 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$414.18 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$192.45 |