| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
1,181 |
1,174 |
$164K |
| D1120 |
Prophylaxis - child |
2,479 |
2,446 |
$88K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,177 |
2,763 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,363 |
1,338 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,607 |
1,584 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,120 |
3,079 |
$44K |
| D1351 |
Sealant - per tooth |
1,667 |
339 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
464 |
247 |
$43K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
270 |
68 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
475 |
467 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
3,014 |
2,946 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,414 |
1,400 |
$26K |
| D1110 |
Prophylaxis - adult |
321 |
315 |
$17K |
| D0274 |
Bitewings - four radiographic images |
420 |
412 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
90 |
$9K |
| D0330 |
Panoramic radiographic image |
246 |
242 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
217 |
199 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
35 |
14 |
$3K |
| D9248 |
|
28 |
27 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
51 |
$939.00 |
| D0603 |
|
4,971 |
4,923 |
$0.00 |