| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,613 |
1,535 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,094 |
1,634 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,089 |
1,046 |
$28K |
| D0145 |
Oral evaluation for a patient under three years of age |
183 |
183 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,967 |
1,825 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
551 |
510 |
$17K |
| D0272 |
Bitewings - two radiographic images |
790 |
750 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,088 |
1,038 |
$14K |
| D1351 |
Sealant - per tooth |
357 |
81 |
$9K |
| D9248 |
|
42 |
40 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
16 |
$4K |
| D1206 |
Topical application of fluoride varnish |
172 |
168 |
$2K |
| D0274 |
Bitewings - four radiographic images |
70 |
66 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
38 |
$973.88 |
| D1110 |
Prophylaxis - adult |
14 |
13 |
$548.80 |
| D0350 |
|
61 |
58 |
$306.94 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$285.86 |
| D0603 |
|
2,707 |
2,652 |
$0.00 |