| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
3,416 |
3,378 |
$472K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,225 |
1,460 |
$458K |
| D1351 |
Sealant - per tooth |
14,702 |
3,399 |
$394K |
| D0120 |
Periodic oral evaluation - established patient |
13,981 |
13,795 |
$392K |
| D1120 |
Prophylaxis - child |
10,930 |
10,781 |
$389K |
| D1110 |
Prophylaxis - adult |
4,620 |
4,568 |
$243K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,332 |
1,552 |
$230K |
| D1208 |
Topical application of fluoride, excluding varnish |
15,284 |
15,092 |
$219K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,577 |
1,676 |
$197K |
| D0272 |
Bitewings - two radiographic images |
8,780 |
8,656 |
$187K |
| D0274 |
Bitewings - four radiographic images |
5,108 |
5,045 |
$154K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,971 |
3,871 |
$103K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,163 |
718 |
$94K |
| D0330 |
Panoramic radiographic image |
2,508 |
2,465 |
$60K |
| D0210 |
Intraoral - complete series of radiographic images |
822 |
822 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,618 |
1,563 |
$53K |
| D7140 |
Extraction, erupted tooth or exposed root |
897 |
534 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
4,036 |
3,907 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,072 |
1,597 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
798 |
783 |
$14K |
| D9248 |
|
25 |
25 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
15 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$380.73 |
| D7111 |
|
21 |
14 |
$204.68 |
| D1330 |
|
222 |
219 |
$24.25 |
| D0603 |
|
19,116 |
18,937 |
$0.00 |