| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
115 |
115 |
$15K |
| D1351 |
Sealant - per tooth |
360 |
54 |
$9K |
| D1120 |
Prophylaxis - child |
238 |
238 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
625 |
251 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
153 |
153 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
243 |
243 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
264 |
264 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
46 |
13 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
82 |
$3K |
| D0240 |
|
282 |
176 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
91 |
87 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$958.58 |
| D0603 |
|
429 |
429 |
$0.00 |