| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
1,237 |
1,226 |
$166K |
| D1351 |
Sealant - per tooth |
5,969 |
1,102 |
$150K |
| D1120 |
Prophylaxis - child |
3,352 |
3,277 |
$114K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
611 |
243 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
2,694 |
2,625 |
$72K |
| D0272 |
Bitewings - two radiographic images |
3,038 |
2,974 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,560 |
3,476 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
3,772 |
3,641 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
547 |
239 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,679 |
3,403 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
695 |
680 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
700 |
678 |
$18K |
| D1110 |
Prophylaxis - adult |
321 |
283 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
60 |
$12K |
| D0274 |
Bitewings - four radiographic images |
305 |
262 |
$6K |
| D9248 |
|
14 |
12 |
$975.04 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$763.79 |
| D0330 |
Panoramic radiographic image |
32 |
28 |
$289.81 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$244.14 |
| D1206 |
Topical application of fluoride varnish |
15 |
12 |
$161.70 |
| D0603 |
|
4,713 |
4,616 |
$0.00 |
| D0601 |
|
39 |
39 |
$0.00 |
| D0602 |
|
23 |
22 |
$0.00 |