| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,853 |
750 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
3,901 |
3,901 |
$101K |
| D1120 |
Prophylaxis - child |
2,715 |
2,715 |
$99K |
| D1110 |
Prophylaxis - adult |
1,174 |
1,174 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,876 |
3,876 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
567 |
361 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,338 |
2,337 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,854 |
1,854 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
475 |
302 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
214 |
149 |
$10K |
| D0274 |
Bitewings - four radiographic images |
185 |
185 |
$5K |
| D0330 |
Panoramic radiographic image |
127 |
127 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
40 |
32 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
220 |
220 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
33 |
29 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
15 |
$2K |
| D1999 |
|
64 |
62 |
$0.00 |