| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
8,277 |
8,275 |
$230K |
| D1110 |
Prophylaxis - adult |
4,053 |
4,052 |
$225K |
| D1120 |
Prophylaxis - child |
4,120 |
4,118 |
$170K |
| D2394 |
|
850 |
592 |
$113K |
| D1351 |
Sealant - per tooth |
2,627 |
989 |
$105K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,883 |
6,881 |
$91K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
626 |
486 |
$54K |
| D0330 |
Panoramic radiographic image |
1,291 |
1,291 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,290 |
1,289 |
$37K |
| D0272 |
Bitewings - two radiographic images |
2,003 |
2,003 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
373 |
314 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
358 |
273 |
$21K |
| D0274 |
Bitewings - four radiographic images |
404 |
404 |
$12K |
| D2335 |
|
52 |
38 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
344 |
343 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
12 |
$1K |
| D9110 |
|
38 |
38 |
$1K |