| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
203 |
200 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,350 |
756 |
$25K |
| D1120 |
Prophylaxis - child |
601 |
588 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
554 |
539 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
93 |
46 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
76 |
$13K |
| D1206 |
Topical application of fluoride varnish |
708 |
693 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
801 |
778 |
$9K |
| D0274 |
Bitewings - four radiographic images |
196 |
190 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
167 |
166 |
$6K |
| D1110 |
Prophylaxis - adult |
99 |
96 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
40 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
150 |
147 |
$4K |
| D1351 |
Sealant - per tooth |
148 |
40 |
$4K |
| D0350 |
|
159 |
156 |
$3K |
| D0272 |
Bitewings - two radiographic images |
97 |
96 |
$2K |
| D9248 |
|
12 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$61.74 |
| D0603 |
|
1,066 |
1,045 |
$0.00 |