| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
485 |
485 |
$22K |
| D1206 |
Topical application of fluoride varnish |
679 |
679 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
660 |
660 |
$16K |
| D1351 |
Sealant - per tooth |
623 |
130 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
111 |
$12K |
| D1110 |
Prophylaxis - adult |
153 |
153 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
59 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
547 |
547 |
$3K |
| D0603 |
|
244 |
244 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
98 |
98 |
$2K |
| D0274 |
Bitewings - four radiographic images |
176 |
176 |
$2K |
| D0272 |
Bitewings - two radiographic images |
210 |
210 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
469 |
469 |
$2K |
| D1353 |
|
99 |
30 |
$990.00 |