| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,663 |
3,598 |
$126K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
885 |
150 |
$110K |
| D1120 |
Prophylaxis - child |
4,449 |
3,524 |
$92K |
| D1206 |
Topical application of fluoride varnish |
2,580 |
2,283 |
$52K |
| D7140 |
Extraction, erupted tooth or exposed root |
415 |
168 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,551 |
1,305 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
759 |
660 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
178 |
120 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,259 |
911 |
$13K |
| D1351 |
Sealant - per tooth |
528 |
186 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
89 |
$10K |
| D0330 |
Panoramic radiographic image |
162 |
157 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
222 |
196 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
15 |
$3K |
| D2330 |
|
45 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$2K |
| D0274 |
Bitewings - four radiographic images |
59 |
57 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
138 |
103 |
$1K |
| D9248 |
|
14 |
13 |
$685.32 |
| D0240 |
|
46 |
44 |
$30.00 |