| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
133 |
132 |
$19K |
| D1120 |
Prophylaxis - child |
457 |
457 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
480 |
480 |
$14K |
| D0272 |
Bitewings - two radiographic images |
406 |
406 |
$8K |
| D1206 |
Topical application of fluoride varnish |
522 |
522 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
87 |
87 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
580 |
579 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
566 |
534 |
$5K |
| D1351 |
Sealant - per tooth |
133 |
28 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
113 |
113 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$2K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$823.20 |
| D0330 |
Panoramic radiographic image |
94 |
94 |
$533.43 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$281.70 |
| D0603 |
|
696 |
695 |
$0.00 |