| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
364 |
335 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
393 |
355 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
55 |
51 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
431 |
395 |
$5K |
| D0272 |
Bitewings - two radiographic images |
273 |
253 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
358 |
310 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
274 |
244 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
109 |
97 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25 |
17 |
$1K |
| D9248 |
|
20 |
17 |
$975.04 |
| D1351 |
Sealant - per tooth |
81 |
19 |
$847.20 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
16 |
$817.53 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$635.76 |
| D1110 |
Prophylaxis - adult |
23 |
21 |
$329.28 |
| D0274 |
Bitewings - four radiographic images |
17 |
16 |
$103.83 |
| D0603 |
|
557 |
521 |
$0.00 |