| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
476 |
475 |
$67K |
| D1120 |
Prophylaxis - child |
1,142 |
1,142 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,175 |
1,174 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,999 |
1,060 |
$20K |
| D0272 |
Bitewings - two radiographic images |
698 |
696 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,179 |
1,171 |
$13K |
| D1351 |
Sealant - per tooth |
466 |
114 |
$13K |
| D1206 |
Topical application of fluoride varnish |
902 |
902 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
430 |
430 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$812.36 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$603.68 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$415.32 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$298.21 |
| D0603 |
|
2,053 |
2,032 |
$0.00 |