| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,487 |
1,487 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
730 |
499 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,576 |
1,576 |
$29K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
342 |
266 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,570 |
1,570 |
$17K |
| D1206 |
Topical application of fluoride varnish |
805 |
805 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
371 |
322 |
$13K |
| D1110 |
Prophylaxis - adult |
295 |
295 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
147 |
125 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
176 |
137 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
504 |
499 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
156 |
$3K |
| D9920 |
|
100 |
100 |
$2K |
| D0240 |
|
67 |
67 |
$1K |
| D1351 |
Sealant - per tooth |
34 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$933.80 |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
96 |
$929.60 |
| D1320 |
|
121 |
121 |
$834.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$63.70 |