| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
8,697 |
2,744 |
$82K |
| D1120 |
Prophylaxis - child |
1,905 |
1,865 |
$64K |
| D0145 |
Oral evaluation for a patient under three years of age |
427 |
420 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,926 |
1,895 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
3,217 |
2,946 |
$34K |
| D1206 |
Topical application of fluoride varnish |
2,111 |
2,075 |
$28K |
| D1351 |
Sealant - per tooth |
1,235 |
222 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
327 |
136 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
175 |
64 |
$21K |
| D0272 |
Bitewings - two radiographic images |
664 |
656 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
154 |
78 |
$10K |
| D9248 |
|
82 |
79 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
366 |
335 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
536 |
496 |
$8K |
| D0330 |
Panoramic radiographic image |
155 |
146 |
$4K |
| D1110 |
Prophylaxis - adult |
50 |
49 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
44 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$626.22 |
| D0274 |
Bitewings - four radiographic images |
13 |
12 |
$346.10 |
| D1330 |
|
24 |
24 |
$122.50 |
| D0601 |
|
1,147 |
1,131 |
$0.00 |
| D0602 |
|
599 |
591 |
$0.00 |
| D0603 |
|
817 |
806 |
$0.00 |