| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
726 |
718 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,064 |
1,053 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,116 |
1,105 |
$28K |
| D1351 |
Sealant - per tooth |
729 |
89 |
$22K |
| D1110 |
Prophylaxis - adult |
340 |
336 |
$21K |
| D1330 |
|
633 |
624 |
$4K |
| D0272 |
Bitewings - two radiographic images |
176 |
174 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$676.08 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$625.82 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$551.40 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$236.19 |