| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
154 |
154 |
$6K |
| D1110 |
Prophylaxis - adult |
117 |
117 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
57 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
167 |
167 |
$5K |
| D0330 |
Panoramic radiographic image |
98 |
98 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$3K |
| D0274 |
Bitewings - four radiographic images |
109 |
109 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
192 |
192 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
35 |
35 |
$969.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$209.95 |