| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,064 |
1,914 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,318 |
2,154 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,674 |
1,564 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
536 |
490 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
64 |
16 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
166 |
53 |
$12K |
| D0272 |
Bitewings - two radiographic images |
875 |
798 |
$8K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$4K |
| D1351 |
Sealant - per tooth |
101 |
33 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
13 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
13 |
$2K |
| D0240 |
|
56 |
25 |
$864.72 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$606.11 |