| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
703 |
703 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
824 |
824 |
$23K |
| D1206 |
Topical application of fluoride varnish |
590 |
590 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
95 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
55 |
47 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
54 |
46 |
$6K |
| D1110 |
Prophylaxis - adult |
67 |
67 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
271 |
271 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
263 |
263 |
$4K |
| D0272 |
Bitewings - two radiographic images |
192 |
192 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
35 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
232 |
232 |
$2K |
| D0160 |
|
56 |
56 |
$2K |
| D1351 |
Sealant - per tooth |
17 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$2K |
| D1320 |
|
66 |
66 |
$528.00 |