| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,046 |
2,046 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,015 |
2,015 |
$54K |
| D1351 |
Sealant - per tooth |
707 |
283 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,548 |
1,548 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
371 |
233 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,664 |
1,664 |
$22K |
| D1206 |
Topical application of fluoride varnish |
718 |
718 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
218 |
177 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,090 |
1,089 |
$14K |
| D1110 |
Prophylaxis - adult |
237 |
237 |
$12K |
| D0274 |
Bitewings - four radiographic images |
360 |
360 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
48 |
40 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
82 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
428 |
428 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
142 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
13 |
13 |
$1K |
| D0240 |
|
63 |
63 |
$990.85 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$342.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$133.00 |