| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
563 |
562 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
694 |
692 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
185 |
97 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
162 |
98 |
$10K |
| D1120 |
Prophylaxis - child |
316 |
316 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
206 |
$7K |
| D0274 |
Bitewings - four radiographic images |
507 |
505 |
$6K |
| D0330 |
Panoramic radiographic image |
144 |
144 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
870 |
854 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
216 |
202 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
222 |
222 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
689 |
674 |
$3K |
| D1351 |
Sealant - per tooth |
79 |
19 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
26 |
13 |
$962.00 |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$502.50 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$406.25 |
| D0603 |
|
17 |
17 |
$170.00 |
| D1330 |
|
220 |
214 |
$0.00 |