| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
761 |
756 |
$26K |
| D0145 |
Oral evaluation for a patient under three years of age |
174 |
174 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
180 |
49 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
657 |
655 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,587 |
599 |
$17K |
| D1351 |
Sealant - per tooth |
410 |
89 |
$10K |
| D0272 |
Bitewings - two radiographic images |
443 |
442 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
927 |
921 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
715 |
697 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
130 |
125 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
48 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
64 |
64 |
$2K |
| D0603 |
|
1,152 |
1,130 |
$0.00 |