| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,076 |
210 |
$26K |
| D1120 |
Prophylaxis - child |
496 |
474 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
495 |
488 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
660 |
638 |
$9K |
| D0274 |
Bitewings - four radiographic images |
196 |
184 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
427 |
133 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
173 |
168 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$1K |
| D1110 |
Prophylaxis - adult |
27 |
26 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
58 |
47 |
$1K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$350.70 |
| D0603 |
|
588 |
571 |
$0.00 |
| D0602 |
|
190 |
185 |
$0.00 |