| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
560 |
551 |
$16K |
| D1351 |
Sealant - per tooth |
478 |
74 |
$13K |
| D1120 |
Prophylaxis - child |
344 |
341 |
$12K |
| D1110 |
Prophylaxis - adult |
170 |
167 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
607 |
599 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
669 |
661 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
59 |
26 |
$8K |
| D0272 |
Bitewings - two radiographic images |
331 |
328 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
625 |
609 |
$7K |
| D0274 |
Bitewings - four radiographic images |
178 |
174 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
32 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
28 |
$729.89 |
| D0603 |
|
135 |
134 |
$0.00 |
| D0602 |
|
429 |
423 |
$0.00 |