| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
495 |
494 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
563 |
561 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
143 |
27 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
546 |
544 |
$12K |
| D1351 |
Sealant - per tooth |
378 |
94 |
$12K |
| D1354 |
|
176 |
55 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
103 |
98 |
$4K |
| D1110 |
Prophylaxis - adult |
78 |
78 |
$4K |
| D0272 |
Bitewings - two radiographic images |
167 |
166 |
$4K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$2K |
| D9248 |
|
16 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$2K |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$880.00 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
27 |
$330.00 |
| D0240 |
|
13 |
13 |
$257.40 |