| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
194 |
178 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
159 |
74 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,270 |
380 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
365 |
357 |
$12K |
| D1351 |
Sealant - per tooth |
436 |
73 |
$11K |
| D1120 |
Prophylaxis - child |
310 |
304 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
45 |
27 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
422 |
405 |
$5K |
| D1206 |
Topical application of fluoride varnish |
349 |
343 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
148 |
134 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
26 |
$3K |
| D0272 |
Bitewings - two radiographic images |
105 |
100 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$566.07 |
| D0120 |
Periodic oral evaluation - established patient |
17 |
17 |
$490.45 |
| D0603 |
|
633 |
598 |
$0.00 |