| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
368 |
349 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,651 |
1,560 |
$43K |
| D1120 |
Prophylaxis - child |
1,276 |
1,196 |
$41K |
| D1351 |
Sealant - per tooth |
1,404 |
237 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,087 |
994 |
$27K |
| D1110 |
Prophylaxis - adult |
573 |
537 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,042 |
1,896 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,950 |
1,787 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,240 |
1,179 |
$16K |
| D0272 |
Bitewings - two radiographic images |
690 |
660 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
40 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
338 |
317 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
126 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
44 |
40 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$777.04 |
| D0330 |
Panoramic radiographic image |
51 |
39 |
$758.98 |
| D0603 |
|
2,714 |
2,567 |
$0.00 |