| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
139 |
136 |
$4K |
| D1110 |
Prophylaxis - adult |
57 |
57 |
$3K |
| D1120 |
Prophylaxis - child |
79 |
77 |
$3K |
| D0272 |
Bitewings - two radiographic images |
111 |
111 |
$3K |
| D1206 |
Topical application of fluoride varnish |
131 |
129 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$877.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
30 |
$758.00 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
40 |
$712.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$185.25 |