| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
873 |
873 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,102 |
1,102 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
994 |
994 |
$21K |
| D1351 |
Sealant - per tooth |
664 |
163 |
$16K |
| D0272 |
Bitewings - two radiographic images |
291 |
291 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
29 |
12 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
25 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
83 |
81 |
$2K |
| D1110 |
Prophylaxis - adult |
65 |
65 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
19 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
69 |
$1K |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$570.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$407.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$308.00 |