| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
293 |
293 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
330 |
330 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
251 |
251 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
244 |
244 |
$4K |
| D0272 |
Bitewings - two radiographic images |
180 |
180 |
$3K |
| D1206 |
Topical application of fluoride varnish |
91 |
91 |
$3K |
| D1351 |
Sealant - per tooth |
37 |
14 |
$2K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
13 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
215 |
215 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
13 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$957.00 |
| D1320 |
|
17 |
17 |
$136.00 |
| D0601 |
|
12 |
12 |
$0.00 |
| D0602 |
|
14 |
14 |
$0.00 |