| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,283 |
2,237 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
995 |
560 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,443 |
2,414 |
$58K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
253 |
51 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,778 |
1,731 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
461 |
257 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,384 |
1,326 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
246 |
129 |
$19K |
| D1110 |
Prophylaxis - adult |
429 |
423 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,025 |
956 |
$12K |
| D0274 |
Bitewings - four radiographic images |
506 |
492 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
317 |
297 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
131 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
48 |
13 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
197 |
180 |
$2K |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$541.60 |
| D1351 |
Sealant - per tooth |
35 |
13 |
$519.60 |