| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
656 |
656 |
$29K |
| D0330 |
Panoramic radiographic image |
143 |
143 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
303 |
303 |
$8K |
| D1110 |
Prophylaxis - adult |
92 |
92 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
46 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
34 |
13 |
$4K |
| D1351 |
Sealant - per tooth |
245 |
51 |
$708.22 |
| D0272 |
Bitewings - two radiographic images |
493 |
493 |
$138.69 |
| D0274 |
Bitewings - four radiographic images |
80 |
80 |
$131.40 |
| D0120 |
Periodic oral evaluation - established patient |
338 |
338 |
$128.86 |
| D1206 |
Topical application of fluoride varnish |
380 |
380 |
$77.83 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
204 |
184 |
$15.87 |
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
29 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
347 |
347 |
$0.00 |