| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,224 |
10,219 |
$402K |
| D0120 |
Periodic oral evaluation - established patient |
9,109 |
9,104 |
$286K |
| D1206 |
Topical application of fluoride varnish |
10,628 |
10,622 |
$280K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
903 |
364 |
$169K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,229 |
788 |
$137K |
| D0272 |
Bitewings - two radiographic images |
3,763 |
3,761 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
809 |
567 |
$73K |
| D1110 |
Prophylaxis - adult |
1,085 |
1,085 |
$56K |
| D7140 |
Extraction, erupted tooth or exposed root |
597 |
350 |
$48K |
| D1351 |
Sealant - per tooth |
1,626 |
522 |
$48K |
| D0140 |
Limited oral evaluation - problem focused |
772 |
767 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
2,209 |
2,189 |
$39K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
101 |
54 |
$13K |
| D9420 |
|
53 |
53 |
$7K |
| D0330 |
Panoramic radiographic image |
88 |
88 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
204 |
98 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$2K |
| D0240 |
|
42 |
42 |
$880.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$827.08 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$578.48 |