| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
346 |
345 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
426 |
425 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
77 |
71 |
$11K |
| D1110 |
Prophylaxis - adult |
133 |
133 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
469 |
469 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
50 |
$6K |
| D0272 |
Bitewings - two radiographic images |
127 |
127 |
$3K |
| D0274 |
Bitewings - four radiographic images |
45 |
45 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$854.05 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$679.25 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$241.30 |