| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,540 |
1,540 |
$56K |
| D1120 |
Prophylaxis - child |
1,159 |
1,158 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
286 |
167 |
$20K |
| D1351 |
Sealant - per tooth |
521 |
149 |
$19K |
| D1110 |
Prophylaxis - adult |
316 |
316 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,194 |
1,193 |
$16K |
| D0272 |
Bitewings - two radiographic images |
860 |
860 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
701 |
701 |
$9K |
| D0274 |
Bitewings - four radiographic images |
299 |
299 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
402 |
399 |
$5K |
| D1206 |
Topical application of fluoride varnish |
218 |
218 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
55 |
40 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
12 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
42 |
42 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$717.47 |
| D1999 |
|
374 |
363 |
$0.00 |
| D1330 |
|
293 |
293 |
$0.00 |
| D0603 |
|
133 |
133 |
$0.00 |
| D1310 |
|
85 |
85 |
$0.00 |
| D0602 |
|
20 |
20 |
$0.00 |