| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
109 |
109 |
$8K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$4K |
| D0330 |
Panoramic radiographic image |
23 |
23 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
16 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$903.30 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$661.97 |
| D1351 |
Sealant - per tooth |
184 |
52 |
$499.92 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$344.26 |
| D0120 |
Periodic oral evaluation - established patient |
147 |
147 |
$116.78 |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
142 |
$18.44 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
33 |
32 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
106 |
106 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
176 |
176 |
$0.00 |