| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,678 |
2,677 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,072 |
644 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,402 |
2,401 |
$64K |
| D1351 |
Sealant - per tooth |
1,369 |
459 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,481 |
1,481 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
2,721 |
2,705 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,198 |
1,197 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
265 |
188 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
549 |
363 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,903 |
1,903 |
$24K |
| D1110 |
Prophylaxis - adult |
422 |
422 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
264 |
188 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
420 |
420 |
$11K |
| D0272 |
Bitewings - two radiographic images |
738 |
737 |
$11K |
| D0330 |
Panoramic radiographic image |
427 |
426 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
224 |
224 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
550 |
549 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$729.00 |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$399.00 |
| D1999 |
|
45 |
41 |
$0.00 |
| D1330 |
|
50 |
50 |
$0.00 |
| D0603 |
|
24 |
24 |
$0.00 |