| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
709 |
706 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,181 |
1,177 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
182 |
52 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
804 |
801 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
160 |
42 |
$11K |
| D0272 |
Bitewings - two radiographic images |
384 |
383 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
129 |
129 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
192 |
192 |
$4K |
| D1110 |
Prophylaxis - adult |
110 |
108 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
126 |
$3K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
123 |
$1K |
| D1351 |
Sealant - per tooth |
31 |
12 |
$657.00 |
| D0140 |
Limited oral evaluation - problem focused |
20 |
20 |
$623.20 |
| D1354 |
|
34 |
13 |
$248.00 |
| D9995 |
|
17 |
17 |
$75.00 |