| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
903 |
898 |
$127K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
695 |
221 |
$102K |
| D1120 |
Prophylaxis - child |
2,666 |
2,638 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
3,041 |
3,016 |
$86K |
| D1351 |
Sealant - per tooth |
3,287 |
738 |
$85K |
| D1206 |
Topical application of fluoride varnish |
2,977 |
2,947 |
$43K |
| D1110 |
Prophylaxis - adult |
583 |
579 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,383 |
1,361 |
$31K |
| D0330 |
Panoramic radiographic image |
263 |
262 |
$16K |
| D0274 |
Bitewings - four radiographic images |
352 |
349 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
935 |
910 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
821 |
467 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
233 |
226 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
168 |
161 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
29 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
174 |
172 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
26 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$244.14 |
| D0602 |
|
882 |
879 |
$0.00 |
| D0603 |
|
3,404 |
3,388 |
$0.00 |