| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,581 |
4,580 |
$155K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,271 |
943 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
4,262 |
4,262 |
$93K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,241 |
5,241 |
$66K |
| D1351 |
Sealant - per tooth |
1,608 |
551 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
794 |
512 |
$42K |
| D0272 |
Bitewings - two radiographic images |
2,289 |
2,289 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
2,588 |
2,582 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
835 |
835 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
173 |
124 |
$13K |
| D1110 |
Prophylaxis - adult |
247 |
247 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
105 |
80 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
106 |
81 |
$8K |
| D0330 |
Panoramic radiographic image |
197 |
197 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
919 |
919 |
$7K |
| D1999 |
|
29 |
29 |
$0.00 |