| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
459 |
450 |
$61K |
| D1120 |
Prophylaxis - child |
1,294 |
1,256 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,170 |
1,142 |
$32K |
| D1351 |
Sealant - per tooth |
1,304 |
241 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
257 |
106 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,536 |
1,498 |
$21K |
| D0272 |
Bitewings - two radiographic images |
905 |
876 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,753 |
1,327 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,476 |
1,414 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
105 |
30 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
319 |
299 |
$10K |
| D1110 |
Prophylaxis - adult |
193 |
191 |
$10K |
| D0274 |
Bitewings - four radiographic images |
230 |
227 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
155 |
142 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
235 |
220 |
$4K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$574.02 |
| D1330 |
|
16 |
16 |
$160.00 |
| D0603 |
|
2,263 |
2,214 |
$0.00 |