| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
522 |
376 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
137 |
33 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
591 |
421 |
$15K |
| D1206 |
Topical application of fluoride varnish |
591 |
426 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
74 |
31 |
$7K |
| D1110 |
Prophylaxis - adult |
115 |
81 |
$5K |
| D1351 |
Sealant - per tooth |
143 |
15 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
118 |
67 |
$4K |
| D0272 |
Bitewings - two radiographic images |
163 |
113 |
$3K |
| D0330 |
Panoramic radiographic image |
55 |
39 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
31 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
30 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
67 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
27 |
$1K |
| D0274 |
Bitewings - four radiographic images |
17 |
13 |
$505.92 |