| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
317 |
317 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
181 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
314 |
314 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
124 |
$3K |
| D0272 |
Bitewings - two radiographic images |
111 |
111 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
65 |
61 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$362.64 |