| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
251 |
251 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
229 |
229 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
285 |
285 |
$5K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
33 |
$3K |
| D0272 |
Bitewings - two radiographic images |
105 |
105 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$2K |
| D1110 |
Prophylaxis - adult |
20 |
20 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
16 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
24 |
$912.21 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$565.18 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$507.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
20 |
$204.75 |