| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
156 |
149 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
121 |
44 |
$17K |
| D1120 |
Prophylaxis - child |
643 |
571 |
$16K |
| D1351 |
Sealant - per tooth |
619 |
120 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
728 |
644 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,723 |
688 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
129 |
81 |
$12K |
| D1206 |
Topical application of fluoride varnish |
836 |
745 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
912 |
749 |
$8K |
| D1110 |
Prophylaxis - adult |
176 |
157 |
$7K |
| D0272 |
Bitewings - two radiographic images |
288 |
268 |
$5K |
| D0274 |
Bitewings - four radiographic images |
165 |
152 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
158 |
152 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
137 |
128 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
31 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
56 |
$974.68 |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$603.47 |
| D1330 |
|
304 |
278 |
$0.00 |
| D0603 |
|
991 |
951 |
$0.00 |