| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
933 |
919 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,062 |
1,047 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,195 |
1,178 |
$17K |
| D0272 |
Bitewings - two radiographic images |
728 |
719 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
343 |
313 |
$9K |
| D1351 |
Sealant - per tooth |
244 |
58 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
30 |
30 |
$4K |
| D0274 |
Bitewings - four radiographic images |
109 |
107 |
$4K |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$3K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
128 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
78 |
45 |
$889.73 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$452.10 |
| D0603 |
|
1,547 |
1,526 |
$0.00 |