| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,587 |
2,578 |
$129K |
| D1310 |
|
1,783 |
1,781 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
1,161 |
1,156 |
$75K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,590 |
2,582 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
790 |
786 |
$53K |
| D0145 |
Oral evaluation for a patient under three years of age |
484 |
484 |
$33K |
| D0603 |
|
1,786 |
1,784 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,538 |
822 |
$25K |
| D1351 |
Sealant - per tooth |
595 |
151 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
221 |
77 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
175 |
78 |
$13K |
| D2330 |
|
166 |
27 |
$12K |
| D9430 |
|
347 |
337 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
863 |
851 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
65 |
30 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
26 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
24 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$624.00 |
| D9993 |
|
20 |
20 |
$0.00 |