| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
927 |
829 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
940 |
819 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
708 |
638 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
189 |
155 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
35 |
13 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
25 |
$3K |
| D1351 |
Sealant - per tooth |
48 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
87 |
86 |
$1K |
| D0240 |
|
37 |
27 |
$540.78 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$494.34 |
| D9920 |
|
60 |
54 |
$0.00 |