| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,375 |
6,333 |
$181K |
| D1120 |
Prophylaxis - child |
4,563 |
4,524 |
$164K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,154 |
1,138 |
$160K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,138 |
5,581 |
$126K |
| D1110 |
Prophylaxis - adult |
2,088 |
2,073 |
$113K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,644 |
6,600 |
$96K |
| D0272 |
Bitewings - two radiographic images |
3,968 |
3,933 |
$91K |
| D1351 |
Sealant - per tooth |
3,220 |
677 |
$82K |
| D0220 |
Intraoral - periapical first radiographic image |
5,746 |
5,693 |
$71K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
473 |
289 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
91 |
13 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
455 |
447 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
83 |
39 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
41 |
$6K |
| D9420 |
|
28 |
28 |
$980.37 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
27 |
$921.87 |
| D0602 |
|
6,100 |
6,055 |
$0.00 |
| D0603 |
|
1,768 |
1,752 |
$0.00 |