| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
514 |
512 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
492 |
489 |
$11K |
| D1206 |
Topical application of fluoride varnish |
233 |
232 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
36 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
215 |
211 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
216 |
215 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
197 |
193 |
$2K |
| D1351 |
Sealant - per tooth |
41 |
15 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
138 |
$1K |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$959.07 |
| D0330 |
Panoramic radiographic image |
16 |
15 |
$445.00 |