| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
476 |
454 |
$16K |
| D1351 |
Sealant - per tooth |
368 |
92 |
$10K |
| D1206 |
Topical application of fluoride varnish |
630 |
608 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
52 |
29 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
258 |
251 |
$7K |
| D0350 |
|
405 |
388 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
157 |
$6K |
| D0272 |
Bitewings - two radiographic images |
254 |
250 |
$5K |
| D9248 |
|
46 |
45 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
34 |
32 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
352 |
234 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
304 |
295 |
$4K |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$2K |
| D0603 |
|
730 |
703 |
$0.00 |