| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
833 |
305 |
$34K |
| D1206 |
Topical application of fluoride varnish |
668 |
233 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
867 |
394 |
$17K |
| D1351 |
Sealant - per tooth |
368 |
30 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
301 |
70 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
104 |
75 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
50 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
43 |
30 |
$1K |
| D0274 |
Bitewings - four radiographic images |
20 |
12 |
$656.00 |