| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
303 |
303 |
$18K |
| D1120 |
Prophylaxis - child |
412 |
409 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
292 |
292 |
$9K |
| D0272 |
Bitewings - two radiographic images |
195 |
195 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
85 |
$2K |
| D1351 |
Sealant - per tooth |
68 |
28 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
50 |
48 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$436.80 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$374.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$141.20 |