| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
231 |
200 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
411 |
380 |
$10K |
| D1120 |
Prophylaxis - child |
159 |
159 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
26 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
206 |
205 |
$4K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$1K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$976.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
22 |
17 |
$924.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$385.00 |