| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,161 |
164 |
$21K |
| D1120 |
Prophylaxis - child |
525 |
499 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
415 |
368 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
664 |
630 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
274 |
271 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
101 |
15 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
321 |
269 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
336 |
190 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
125 |
106 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
83 |
76 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D1330 |
|
104 |
95 |
$469.25 |
| D0603 |
|
924 |
895 |
$0.00 |
| D0602 |
|
20 |
15 |
$0.00 |
| D0601 |
|
19 |
15 |
$0.00 |