| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
957 |
954 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
918 |
915 |
$29K |
| D1206 |
Topical application of fluoride varnish |
961 |
958 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
63 |
$11K |
| D0272 |
Bitewings - two radiographic images |
404 |
404 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
307 |
302 |
$5K |
| D1351 |
Sealant - per tooth |
72 |
37 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$159.93 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
334 |
318 |
$0.00 |