| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
127 |
85 |
$1K |
| D1206 |
Topical application of fluoride varnish |
149 |
98 |
$1K |
| D1351 |
Sealant - per tooth |
90 |
12 |
$997.90 |
| D0120 |
Periodic oral evaluation - established patient |
141 |
96 |
$970.94 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
90 |
57 |
$804.70 |
| D0272 |
Bitewings - two radiographic images |
87 |
59 |
$471.39 |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
40 |
$278.25 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$51.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
16 |
$22.39 |