| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
641 |
641 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
301 |
130 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
590 |
590 |
$19K |
| D1351 |
Sealant - per tooth |
211 |
71 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
440 |
440 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
42 |
26 |
$5K |
| D1206 |
Topical application of fluoride varnish |
125 |
125 |
$4K |
| D0272 |
Bitewings - two radiographic images |
264 |
264 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
43 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
100 |
$3K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$3K |
| D1353 |
|
106 |
45 |
$2K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
14 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
104 |
103 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
15 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
41 |
$234.00 |
| D0601 |
|
28 |
28 |
$0.00 |
| D0602 |
|
27 |
27 |
$0.00 |
| D1330 |
|
260 |
260 |
$0.00 |
| D0603 |
|
145 |
145 |
$0.00 |