| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
673 |
673 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
700 |
700 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
763 |
763 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
92 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
119 |
55 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
64 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
52 |
32 |
$6K |
| D0272 |
Bitewings - two radiographic images |
383 |
383 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
39 |
29 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
93 |
$3K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$1K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$967.68 |
| D0220 |
Intraoral - periapical first radiographic image |
145 |
145 |
$761.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
49 |
$504.00 |