| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,437 |
2,430 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
868 |
542 |
$51K |
| D1351 |
Sealant - per tooth |
1,810 |
340 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,505 |
2,491 |
$48K |
| D1120 |
Prophylaxis - child |
1,626 |
1,619 |
$42K |
| D1110 |
Prophylaxis - adult |
886 |
881 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
462 |
218 |
$23K |
| D0274 |
Bitewings - four radiographic images |
668 |
664 |
$20K |
| D0272 |
Bitewings - two radiographic images |
894 |
891 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
139 |
39 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
271 |
200 |
$13K |
| D0330 |
Panoramic radiographic image |
213 |
212 |
$8K |
| D0603 |
|
770 |
769 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
81 |
57 |
$5K |
| D1330 |
|
1,004 |
1,003 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
131 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
37 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
228 |
225 |
$2K |
| D0602 |
|
169 |
169 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$1K |
| D0240 |
|
79 |
64 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$528.00 |
| D1310 |
|
15 |
15 |
$192.23 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
26 |
$187.05 |