| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
2,687 |
2,672 |
$363K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,518 |
687 |
$206K |
| D1120 |
Prophylaxis - child |
5,209 |
5,145 |
$175K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,912 |
920 |
$174K |
| D1351 |
Sealant - per tooth |
5,101 |
934 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
4,128 |
4,074 |
$110K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,913 |
4,501 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,986 |
2,939 |
$95K |
| D1206 |
Topical application of fluoride varnish |
6,198 |
6,122 |
$83K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,450 |
2,282 |
$62K |
| D0330 |
Panoramic radiographic image |
1,867 |
1,836 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
770 |
443 |
$57K |
| D1110 |
Prophylaxis - adult |
902 |
893 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
5,298 |
5,158 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
604 |
604 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
695 |
421 |
$38K |
| D0272 |
Bitewings - two radiographic images |
2,373 |
2,330 |
$32K |
| D2934 |
|
99 |
26 |
$14K |
| D0274 |
Bitewings - four radiographic images |
546 |
539 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
57 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
473 |
463 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
81 |
38 |
$7K |
| D9420 |
|
125 |
125 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
45 |
$646.80 |
| D0270 |
|
13 |
13 |
$53.90 |
| D0603 |
|
9,566 |
9,481 |
$0.00 |
| D0602 |
|
204 |
204 |
$0.00 |