| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
434 |
433 |
$61K |
| D1120 |
Prophylaxis - child |
1,481 |
1,474 |
$52K |
| D9248 |
|
417 |
414 |
$49K |
| D1351 |
Sealant - per tooth |
1,729 |
470 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,439 |
1,430 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
454 |
358 |
$35K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
192 |
141 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,233 |
789 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,619 |
1,610 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
996 |
979 |
$12K |
| D0272 |
Bitewings - two radiographic images |
452 |
448 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
124 |
124 |
$3K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
13 |
$1K |
| D9420 |
|
14 |
14 |
$508.34 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$416.78 |
| D0603 |
|
2,196 |
2,184 |
$0.00 |
| D0350 |
|
12 |
12 |
$0.00 |