| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
478 |
471 |
$65K |
| D1120 |
Prophylaxis - child |
1,428 |
1,398 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
495 |
221 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,413 |
1,388 |
$39K |
| D1351 |
Sealant - per tooth |
952 |
201 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,382 |
1,764 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,107 |
1,083 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,506 |
1,482 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,943 |
1,901 |
$20K |
| D1110 |
Prophylaxis - adult |
338 |
336 |
$17K |
| D0274 |
Bitewings - four radiographic images |
439 |
434 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
369 |
358 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
60 |
26 |
$9K |
| D9248 |
|
64 |
55 |
$7K |
| D0330 |
Panoramic radiographic image |
319 |
314 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$5K |
| D0350 |
|
819 |
797 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
179 |
161 |
$4K |
| D1206 |
Topical application of fluoride varnish |
301 |
296 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
14 |
$2K |
| D1330 |
|
46 |
45 |
$428.75 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$244.14 |
| D9211 |
|
15 |
12 |
$75.00 |
| D0603 |
|
1,732 |
1,701 |
$0.00 |
| D0602 |
|
550 |
542 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |
| D2991 |
|
315 |
84 |
$0.00 |