| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
1,757 |
1,748 |
$247K |
| D1120 |
Prophylaxis - child |
3,425 |
3,399 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
3,165 |
3,143 |
$90K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
512 |
224 |
$73K |
| D0272 |
Bitewings - two radiographic images |
2,587 |
2,567 |
$57K |
| D1206 |
Topical application of fluoride varnish |
3,781 |
3,754 |
$55K |
| D1351 |
Sealant - per tooth |
1,822 |
572 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,084 |
1,597 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
988 |
978 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
254 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,161 |
1,102 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
2,359 |
2,294 |
$28K |
| D1110 |
Prophylaxis - adult |
437 |
435 |
$23K |
| D0274 |
Bitewings - four radiographic images |
568 |
565 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
205 |
138 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
25 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
55 |
52 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$396.90 |
| D0603 |
|
6,000 |
5,965 |
$0.00 |