| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
815 |
799 |
$26K |
| D1206 |
Topical application of fluoride varnish |
868 |
854 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
569 |
558 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
262 |
105 |
$15K |
| D0330 |
Panoramic radiographic image |
287 |
282 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
339 |
291 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
162 |
49 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
68 |
16 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
300 |
296 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
49 |
$6K |
| D1110 |
Prophylaxis - adult |
131 |
127 |
$5K |
| D0272 |
Bitewings - two radiographic images |
224 |
221 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
277 |
88 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
139 |
$2K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$301.56 |
| D1330 |
|
88 |
87 |
$0.00 |