| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
243 |
239 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
189 |
185 |
$6K |
| D1206 |
Topical application of fluoride varnish |
248 |
241 |
$5K |
| D1351 |
Sealant - per tooth |
128 |
46 |
$4K |
| D0272 |
Bitewings - two radiographic images |
142 |
137 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
82 |
80 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
65 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0240 |
|
25 |
19 |
$750.75 |