| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
172 |
169 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,711 |
833 |
$12K |
| D1120 |
Prophylaxis - child |
414 |
390 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
494 |
464 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
67 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
912 |
864 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
954 |
901 |
$7K |
| D0274 |
Bitewings - four radiographic images |
298 |
282 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
175 |
$5K |
| D1351 |
Sealant - per tooth |
166 |
42 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
72 |
67 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
140 |
114 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$706.40 |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$429.79 |
| D0603 |
|
1,019 |
971 |
$0.01 |
| D0602 |
|
81 |
79 |
$0.00 |