| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
113 |
113 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
14 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
115 |
115 |
$3K |
| D1110 |
Prophylaxis - adult |
51 |
51 |
$3K |
| D0274 |
Bitewings - four radiographic images |
73 |
73 |
$3K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$2K |
| D0272 |
Bitewings - two radiographic images |
71 |
71 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
90 |
$2K |
| D1206 |
Topical application of fluoride varnish |
80 |
80 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
53 |
$825.27 |
| D0230 |
Intraoral - periapical each additional radiographic image |
48 |
48 |
$601.53 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$480.91 |