| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
1,230 |
1,213 |
$169K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,261 |
580 |
$120K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
863 |
196 |
$119K |
| D1120 |
Prophylaxis - child |
3,486 |
3,410 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
3,428 |
3,359 |
$93K |
| D1206 |
Topical application of fluoride varnish |
3,988 |
3,904 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,714 |
1,314 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
457 |
262 |
$32K |
| D1110 |
Prophylaxis - adult |
506 |
501 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
895 |
830 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,135 |
1,097 |
$22K |
| D0240 |
|
2,359 |
1,140 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,584 |
1,525 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
504 |
489 |
$17K |
| D1351 |
Sealant - per tooth |
491 |
125 |
$13K |
| D0274 |
Bitewings - four radiographic images |
297 |
288 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
189 |
185 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
55 |
27 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
29 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
13 |
$559.18 |
| D0603 |
|
5,361 |
5,265 |
$0.00 |