| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
577 |
575 |
$81K |
| D1120 |
Prophylaxis - child |
1,742 |
1,722 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,164 |
2,145 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
587 |
276 |
$58K |
| D1351 |
Sealant - per tooth |
1,927 |
353 |
$53K |
| D1110 |
Prophylaxis - adult |
963 |
957 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,195 |
1,187 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,373 |
2,348 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,854 |
2,817 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,183 |
1,171 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,663 |
2,637 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
389 |
385 |
$13K |
| D0330 |
Panoramic radiographic image |
176 |
174 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
138 |
132 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
18 |
$2K |
| D1206 |
Topical application of fluoride varnish |
35 |
34 |
$455.70 |
| D1330 |
|
24 |
24 |
$280.53 |
| D0601 |
|
720 |
713 |
$0.00 |
| D0602 |
|
1,837 |
1,825 |
$0.00 |
| D0603 |
|
723 |
719 |
$0.00 |