| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,822 |
2,821 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,104 |
625 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,570 |
2,570 |
$64K |
| D1206 |
Topical application of fluoride varnish |
2,410 |
2,410 |
$61K |
| D1351 |
Sealant - per tooth |
1,369 |
441 |
$49K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
595 |
156 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
2,431 |
2,415 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
582 |
310 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,112 |
1,112 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
442 |
261 |
$20K |
| D1110 |
Prophylaxis - adult |
394 |
394 |
$18K |
| D0272 |
Bitewings - two radiographic images |
945 |
945 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,602 |
1,541 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
797 |
797 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
422 |
422 |
$9K |
| D2335 |
|
32 |
13 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
28 |
16 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
114 |
114 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
52 |
52 |
$1K |
| D0240 |
|
73 |
40 |
$409.50 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$111.94 |