| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,707 |
1,688 |
$42K |
| D1351 |
Sealant - per tooth |
1,910 |
352 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,204 |
1,204 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
492 |
345 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,532 |
1,530 |
$10K |
| D1206 |
Topical application of fluoride varnish |
235 |
228 |
$4K |
| D0330 |
Panoramic radiographic image |
218 |
218 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
256 |
165 |
$3K |
| D0273 |
|
426 |
426 |
$2K |
| D0603 |
|
245 |
242 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
123 |
75 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
222 |
170 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
117 |
72 |
$897.00 |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
20 |
$720.00 |
| D0602 |
|
61 |
61 |
$600.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$108.10 |
| D0272 |
Bitewings - two radiographic images |
19 |
19 |
$0.00 |
| D9986 |
|
1,491 |
1,425 |
$0.00 |