| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
481 |
479 |
$26K |
| D1206 |
Topical application of fluoride varnish |
481 |
479 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
411 |
409 |
$14K |
| D1351 |
Sealant - per tooth |
369 |
56 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
26 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
143 |
143 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
221 |
210 |
$4K |
| D0272 |
Bitewings - two radiographic images |
127 |
127 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
255 |
251 |
$2K |
| D0603 |
|
471 |
468 |
$2K |