| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
912 |
909 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
3,325 |
3,294 |
$94K |
| D1120 |
Prophylaxis - child |
2,575 |
2,549 |
$93K |
| D1351 |
Sealant - per tooth |
2,772 |
724 |
$76K |
| D0272 |
Bitewings - two radiographic images |
2,237 |
2,216 |
$50K |
| D1206 |
Topical application of fluoride varnish |
3,385 |
3,354 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
515 |
336 |
$47K |
| D1110 |
Prophylaxis - adult |
826 |
818 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
436 |
296 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
798 |
786 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
803 |
777 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
32 |
12 |
$4K |
| D0274 |
Bitewings - four radiographic images |
67 |
64 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$817.27 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$126.61 |
| D0601 |
|
854 |
846 |
$0.00 |
| D0603 |
|
2,385 |
2,372 |
$0.00 |
| D0602 |
|
1,103 |
1,100 |
$0.00 |