| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,532 |
1,514 |
$43K |
| D1351 |
Sealant - per tooth |
1,616 |
286 |
$42K |
| D1110 |
Prophylaxis - adult |
779 |
765 |
$41K |
| D1120 |
Prophylaxis - child |
839 |
832 |
$30K |
| D0274 |
Bitewings - four radiographic images |
749 |
740 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,635 |
1,622 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,268 |
1,245 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
140 |
52 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,222 |
1,198 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
147 |
145 |
$10K |
| D0272 |
Bitewings - two radiographic images |
156 |
156 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
104 |
101 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
28 |
$948.73 |
| D0603 |
|
957 |
953 |
$165.06 |
| D0601 |
|
600 |
594 |
$0.00 |