| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
86 |
86 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
50 |
$5K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
145 |
145 |
$221.82 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
57 |
52 |
$50.23 |
| D0274 |
Bitewings - four radiographic images |
20 |
20 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
38 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
105 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
62 |
62 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
17 |
$0.00 |