| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
667 |
666 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
725 |
724 |
$22K |
| D1206 |
Topical application of fluoride varnish |
661 |
660 |
$13K |
| D0272 |
Bitewings - two radiographic images |
335 |
335 |
$8K |
| D1110 |
Prophylaxis - adult |
81 |
81 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
66 |
62 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
37 |
12 |
$967.68 |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
28 |
$964.72 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$553.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$142.48 |