| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
622 |
619 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
895 |
893 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
741 |
738 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
189 |
107 |
$12K |
| D1351 |
Sealant - per tooth |
452 |
78 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
231 |
231 |
$10K |
| D1110 |
Prophylaxis - adult |
276 |
275 |
$10K |
| D0272 |
Bitewings - two radiographic images |
381 |
379 |
$6K |
| D0330 |
Panoramic radiographic image |
77 |
77 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
95 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
24 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$1K |
| D1330 |
|
124 |
124 |
$620.00 |
| D0602 |
|
13 |
13 |
$130.00 |