| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
734 |
195 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
392 |
225 |
$20K |
| D1120 |
Prophylaxis - child |
574 |
574 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
380 |
380 |
$8K |
| D0272 |
Bitewings - two radiographic images |
510 |
510 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
395 |
395 |
$4K |
| D1206 |
Topical application of fluoride varnish |
197 |
197 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
424 |
422 |
$4K |
| D0330 |
Panoramic radiographic image |
117 |
117 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
145 |
145 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
351 |
350 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
19 |
14 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
17 |
12 |
$911.03 |
| D0210 |
Intraoral - complete series of radiographic images |
97 |
97 |
$198.90 |