| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
745 |
742 |
$103K |
| D1120 |
Prophylaxis - child |
1,393 |
1,374 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,074 |
1,689 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,241 |
1,229 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,867 |
1,846 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,982 |
1,936 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
486 |
477 |
$16K |
| D1110 |
Prophylaxis - adult |
225 |
224 |
$12K |
| D0272 |
Bitewings - two radiographic images |
426 |
424 |
$10K |
| D1351 |
Sealant - per tooth |
325 |
52 |
$8K |
| D0274 |
Bitewings - four radiographic images |
239 |
236 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
30 |
12 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
53 |
$995.34 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
15 |
$404.57 |
| D0603 |
|
2,637 |
2,616 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |