| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
1,312 |
1,301 |
$180K |
| D1120 |
Prophylaxis - child |
4,121 |
4,094 |
$142K |
| D0120 |
Periodic oral evaluation - established patient |
3,555 |
3,535 |
$98K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
697 |
220 |
$95K |
| D9248 |
|
493 |
467 |
$57K |
| D1351 |
Sealant - per tooth |
2,092 |
449 |
$56K |
| D1206 |
Topical application of fluoride varnish |
3,925 |
3,899 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
527 |
228 |
$45K |
| D0272 |
Bitewings - two radiographic images |
1,905 |
1,882 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
1,528 |
1,478 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,326 |
1,023 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
368 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
409 |
394 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
97 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
47 |
24 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
25 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
51 |
$1K |
| D0603 |
|
5,223 |
5,189 |
$0.00 |
| D0602 |
|
13 |
12 |
$0.00 |