| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
1,053 |
1,046 |
$147K |
| D1351 |
Sealant - per tooth |
3,091 |
729 |
$83K |
| D1120 |
Prophylaxis - child |
1,514 |
1,505 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,855 |
1,487 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
599 |
591 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,016 |
1,006 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,163 |
1,157 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,256 |
2,243 |
$32K |
| D1110 |
Prophylaxis - adult |
606 |
602 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,575 |
1,564 |
$19K |
| D0272 |
Bitewings - two radiographic images |
495 |
494 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
76 |
25 |
$11K |
| D0274 |
Bitewings - four radiographic images |
178 |
178 |
$6K |
| D9248 |
|
42 |
41 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
57 |
56 |
$2K |
| D0603 |
|
3,467 |
3,429 |
$0.00 |