| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
1,017 |
983 |
$131K |
| D1351 |
Sealant - per tooth |
5,819 |
804 |
$119K |
| D1120 |
Prophylaxis - child |
3,187 |
2,955 |
$99K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
779 |
225 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,619 |
2,421 |
$66K |
| D0272 |
Bitewings - two radiographic images |
2,955 |
2,734 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
3,534 |
3,252 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,863 |
2,629 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,457 |
3,049 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
507 |
452 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
152 |
85 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
434 |
372 |
$8K |
| D9248 |
|
162 |
144 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
53 |
$5K |
| D1110 |
Prophylaxis - adult |
121 |
101 |
$5K |
| D1206 |
Topical application of fluoride varnish |
301 |
285 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
47 |
15 |
$3K |
| D0274 |
Bitewings - four radiographic images |
139 |
115 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$918.32 |
| D0330 |
Panoramic radiographic image |
63 |
53 |
$454.05 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$206.58 |
| D0603 |
|
4,144 |
3,907 |
$0.00 |
| D0602 |
|
214 |
165 |
$0.00 |
| D0601 |
|
95 |
93 |
$0.00 |