| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
738 |
731 |
$31K |
| D1206 |
Topical application of fluoride varnish |
947 |
938 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
736 |
731 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
112 |
$19K |
| D1351 |
Sealant - per tooth |
186 |
70 |
$6K |
| D1352 |
|
161 |
71 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
44 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
271 |
253 |
$5K |
| D1110 |
Prophylaxis - adult |
66 |
66 |
$4K |
| D0272 |
Bitewings - two radiographic images |
223 |
222 |
$3K |
| D0330 |
Panoramic radiographic image |
77 |
77 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
57 |
$3K |
| D1330 |
|
452 |
446 |
$3K |
| D0274 |
Bitewings - four radiographic images |
79 |
78 |
$2K |