| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
723 |
723 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
837 |
837 |
$24K |
| D1206 |
Topical application of fluoride varnish |
801 |
801 |
$23K |
| D0272 |
Bitewings - two radiographic images |
294 |
294 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
300 |
300 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
303 |
303 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
40 |
13 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$686.72 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
25 |
$646.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$182.00 |