| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
812 |
809 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,071 |
1,069 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,107 |
1,104 |
$19K |
| D1110 |
Prophylaxis - adult |
233 |
232 |
$9K |
| D0272 |
Bitewings - two radiographic images |
335 |
332 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
187 |
175 |
$4K |
| D0603 |
|
309 |
308 |
$3K |
| D1330 |
|
217 |
216 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
12 |
$2K |
| D1999 |
|
321 |
302 |
$1K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$1K |
| D0601 |
|
72 |
72 |
$759.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$52.00 |