| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
429 |
429 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
544 |
543 |
$14K |
| D1110 |
Prophylaxis - adult |
165 |
164 |
$8K |
| D1206 |
Topical application of fluoride varnish |
255 |
253 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
278 |
278 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
34 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
50 |
$3K |
| D1351 |
Sealant - per tooth |
46 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
110 |
110 |
$2K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$877.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$395.25 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$376.90 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$343.50 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$60.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
117 |
116 |
$45.00 |