| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
309 |
303 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
253 |
251 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
657 |
635 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
138 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
147 |
143 |
$10K |
| D1351 |
Sealant - per tooth |
486 |
148 |
$7K |
| D2330 |
|
33 |
14 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
140 |
44 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
197 |
119 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
36 |
$937.26 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
27 |
$514.39 |
| D1206 |
Topical application of fluoride varnish |
101 |
97 |
$464.65 |
| D9920 |
|
100 |
78 |
$354.02 |
| D1120 |
Prophylaxis - child |
577 |
565 |
$246.32 |
| D1208 |
Topical application of fluoride, excluding varnish |
617 |
607 |
$32.35 |
| D0230 |
Intraoral - periapical each additional radiographic image |
874 |
592 |
$0.00 |
| D1330 |
|
551 |
542 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
45 |
17 |
$0.00 |
| D1110 |
Prophylaxis - adult |
112 |
111 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
191 |
188 |
$0.00 |