| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
793 |
790 |
$111K |
| D1351 |
Sealant - per tooth |
4,091 |
1,152 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
3,356 |
3,327 |
$95K |
| D1120 |
Prophylaxis - child |
2,571 |
2,552 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
698 |
402 |
$65K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,602 |
3,566 |
$52K |
| D0272 |
Bitewings - two radiographic images |
2,403 |
2,383 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,583 |
3,660 |
$46K |
| D1110 |
Prophylaxis - adult |
856 |
844 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
3,856 |
3,816 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
520 |
357 |
$39K |
| D9248 |
|
235 |
228 |
$27K |
| D0274 |
Bitewings - four radiographic images |
849 |
839 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
156 |
91 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
663 |
651 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
207 |
133 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
137 |
137 |
$8K |
| D0330 |
Panoramic radiographic image |
454 |
446 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
152 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
224 |
219 |
$4K |
| D0350 |
|
39 |
39 |
$441.12 |
| D0603 |
|
4,843 |
4,787 |
$0.00 |