| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
587 |
576 |
$80K |
| D1351 |
Sealant - per tooth |
2,110 |
317 |
$50K |
| D1120 |
Prophylaxis - child |
1,270 |
1,235 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,136 |
1,102 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
303 |
139 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,741 |
1,679 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,345 |
1,088 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
616 |
598 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
310 |
299 |
$20K |
| D1110 |
Prophylaxis - adult |
379 |
368 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,193 |
1,147 |
$14K |
| D0272 |
Bitewings - two radiographic images |
299 |
297 |
$7K |
| D0274 |
Bitewings - four radiographic images |
204 |
195 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
174 |
145 |
$4K |
| D1330 |
|
56 |
56 |
$600.00 |
| D0602 |
|
814 |
797 |
$0.00 |
| D0603 |
|
1,787 |
1,734 |
$0.00 |