| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,203 |
2,203 |
$111K |
| D0120 |
Periodic oral evaluation - established patient |
2,132 |
2,132 |
$79K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,059 |
2,059 |
$61K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
260 |
203 |
$59K |
| D1351 |
Sealant - per tooth |
491 |
289 |
$50K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
236 |
203 |
$32K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
203 |
163 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
240 |
201 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,247 |
1,246 |
$23K |
| D1110 |
Prophylaxis - adult |
240 |
240 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
124 |
110 |
$14K |
| D1206 |
Topical application of fluoride varnish |
365 |
365 |
$13K |
| D0330 |
Panoramic radiographic image |
278 |
278 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
315 |
315 |
$10K |
| D0274 |
Bitewings - four radiographic images |
177 |
177 |
$5K |