| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
358 |
358 |
$50K |
| D1120 |
Prophylaxis - child |
1,154 |
1,146 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,325 |
1,318 |
$37K |
| D1351 |
Sealant - per tooth |
1,312 |
234 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
118 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,521 |
1,321 |
$25K |
| D0274 |
Bitewings - four radiographic images |
694 |
688 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,381 |
1,371 |
$20K |
| D1110 |
Prophylaxis - adult |
348 |
346 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,440 |
1,423 |
$16K |
| D0272 |
Bitewings - two radiographic images |
403 |
401 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
182 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
16 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
43 |
$1K |
| D1330 |
|
96 |
95 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
47 |
$690.90 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$470.09 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$261.04 |
| D0603 |
|
207 |
206 |
$0.00 |
| D0602 |
|
1,760 |
1,746 |
$0.00 |