| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
842 |
834 |
$24K |
| D0145 |
Oral evaluation for a patient under three years of age |
165 |
162 |
$23K |
| D1120 |
Prophylaxis - child |
497 |
495 |
$18K |
| D1110 |
Prophylaxis - adult |
325 |
321 |
$18K |
| D1351 |
Sealant - per tooth |
616 |
164 |
$17K |
| D0240 |
|
1,730 |
831 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
933 |
925 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
84 |
48 |
$13K |
| D0274 |
Bitewings - four radiographic images |
344 |
338 |
$11K |
| D0272 |
Bitewings - two radiographic images |
412 |
409 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
73 |
43 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
32 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
88 |
83 |
$1K |
| D1330 |
|
107 |
107 |
$24.50 |
| D0601 |
|
727 |
719 |
$0.00 |
| D0602 |
|
333 |
332 |
$0.00 |