| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
185 |
169 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
843 |
770 |
$22K |
| D1120 |
Prophylaxis - child |
637 |
579 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
866 |
793 |
$12K |
| D1110 |
Prophylaxis - adult |
221 |
206 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
923 |
442 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
70 |
$9K |
| D0272 |
Bitewings - two radiographic images |
388 |
358 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
295 |
274 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
560 |
511 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
41 |
$5K |
| D0274 |
Bitewings - four radiographic images |
133 |
124 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
26 |
12 |
$4K |
| D1351 |
Sealant - per tooth |
44 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$876.40 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$225.36 |
| D0270 |
|
18 |
15 |
$73.50 |
| D0603 |
|
1,066 |
976 |
$0.00 |