| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
479 |
93 |
$13K |
| D1120 |
Prophylaxis - child |
309 |
307 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
356 |
353 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
44 |
$7K |
| D1206 |
Topical application of fluoride varnish |
392 |
390 |
$5K |
| D0272 |
Bitewings - two radiographic images |
170 |
169 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20 |
12 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
63 |
58 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
133 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
98 |
$1K |
| D0601 |
|
195 |
193 |
$0.00 |
| D0603 |
|
107 |
105 |
$0.00 |