| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
333 |
324 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,535 |
905 |
$40K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
249 |
58 |
$35K |
| D1120 |
Prophylaxis - child |
639 |
627 |
$23K |
| D9248 |
|
145 |
143 |
$17K |
| D1351 |
Sealant - per tooth |
650 |
117 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
449 |
436 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,005 |
969 |
$11K |
| D1206 |
Topical application of fluoride varnish |
779 |
757 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
100 |
31 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
222 |
$8K |
| D1110 |
Prophylaxis - adult |
100 |
96 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
18 |
$4K |
| D0274 |
Bitewings - four radiographic images |
101 |
97 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
157 |
153 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
47 |
46 |
$1K |
| D0603 |
|
1,248 |
1,208 |
$0.00 |