| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,941 |
412 |
$50K |
| D1120 |
Prophylaxis - child |
1,069 |
1,050 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,257 |
1,237 |
$35K |
| D0145 |
Oral evaluation for a patient under three years of age |
236 |
235 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,410 |
1,388 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
123 |
29 |
$15K |
| D0272 |
Bitewings - two radiographic images |
581 |
569 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,051 |
377 |
$11K |
| D1110 |
Prophylaxis - adult |
134 |
131 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
593 |
554 |
$7K |
| D0274 |
Bitewings - four radiographic images |
161 |
158 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
20 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
128 |
112 |
$3K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$765.36 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$221.60 |
| D0603 |
|
1,680 |
1,655 |
$0.00 |
| D0602 |
|
76 |
74 |
$0.00 |
| D0601 |
|
16 |
16 |
$0.00 |