| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
825 |
128 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
568 |
564 |
$16K |
| D1120 |
Prophylaxis - child |
370 |
369 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
63 |
20 |
$9K |
| D1110 |
Prophylaxis - adult |
169 |
167 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
608 |
605 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
632 |
629 |
$8K |
| D0272 |
Bitewings - two radiographic images |
308 |
306 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
612 |
609 |
$7K |
| D0274 |
Bitewings - four radiographic images |
137 |
135 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
46 |
16 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
15 |
$2K |
| D9248 |
|
16 |
15 |
$2K |
| D0602 |
|
227 |
225 |
$0.00 |
| D0603 |
|
395 |
392 |
$0.00 |