| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,518 |
3,415 |
$123K |
| D0145 |
Oral evaluation for a patient under three years of age |
861 |
837 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
3,444 |
3,367 |
$96K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,735 |
3,621 |
$53K |
| D0272 |
Bitewings - two radiographic images |
2,009 |
1,939 |
$45K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
342 |
81 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
245 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
689 |
639 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
622 |
576 |
$7K |
| D0330 |
Panoramic radiographic image |
84 |
80 |
$5K |
| D1351 |
Sealant - per tooth |
67 |
16 |
$1K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
25 |
$807.81 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
24 |
13 |
$379.54 |
| D0601 |
|
2,697 |
2,615 |
$0.00 |
| D0602 |
|
1,642 |
1,597 |
$0.00 |
| D0603 |
|
519 |
505 |
$0.00 |