| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
1,663 |
1,657 |
$231K |
| D1120 |
Prophylaxis - child |
5,797 |
5,744 |
$200K |
| D0120 |
Periodic oral evaluation - established patient |
5,981 |
5,936 |
$163K |
| D1351 |
Sealant - per tooth |
4,399 |
895 |
$119K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,109 |
521 |
$102K |
| D1206 |
Topical application of fluoride varnish |
6,476 |
6,418 |
$90K |
| D0272 |
Bitewings - two radiographic images |
3,572 |
3,546 |
$80K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
496 |
215 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,842 |
2,134 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
2,826 |
2,764 |
$33K |
| D1110 |
Prophylaxis - adult |
623 |
620 |
$32K |
| D0274 |
Bitewings - four radiographic images |
959 |
952 |
$31K |
| D9248 |
|
171 |
170 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
604 |
589 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
563 |
547 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
38 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
133 |
132 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$892.92 |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$563.40 |
| D0601 |
|
3,691 |
3,659 |
$0.00 |
| D0603 |
|
2,377 |
2,362 |
$0.00 |
| D0602 |
|
2,436 |
2,422 |
$0.00 |