| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,522 |
3,521 |
$144K |
| D0120 |
Periodic oral evaluation - established patient |
4,335 |
4,334 |
$119K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,221 |
768 |
$80K |
| D0274 |
Bitewings - four radiographic images |
2,805 |
2,805 |
$77K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
632 |
409 |
$69K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,025 |
682 |
$51K |
| D1351 |
Sealant - per tooth |
1,179 |
418 |
$48K |
| D1206 |
Topical application of fluoride varnish |
1,690 |
1,689 |
$48K |
| D1110 |
Prophylaxis - adult |
806 |
806 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,257 |
3,241 |
$44K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
503 |
337 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
661 |
441 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,630 |
2,630 |
$35K |
| D1354 |
|
609 |
130 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,084 |
1,076 |
$17K |
| D0272 |
Bitewings - two radiographic images |
568 |
568 |
$9K |
| D8670 |
Periodic orthodontic treatment visit |
18 |
18 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
38 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
73 |
73 |
$968.70 |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$427.50 |
| D9110 |
|
13 |
13 |
$357.50 |