| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,903 |
1,890 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,558 |
2,539 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
2,314 |
2,298 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
689 |
286 |
$41K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
339 |
121 |
$34K |
| D1110 |
Prophylaxis - adult |
470 |
470 |
$19K |
| D0272 |
Bitewings - two radiographic images |
921 |
910 |
$17K |
| D1330 |
|
1,498 |
1,494 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
170 |
78 |
$10K |
| D0274 |
Bitewings - four radiographic images |
315 |
315 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
166 |
86 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
158 |
158 |
$8K |
| D1310 |
|
693 |
690 |
$8K |
| D0603 |
|
635 |
634 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
53 |
$5K |
| D0330 |
Panoramic radiographic image |
68 |
68 |
$3K |
| D0240 |
|
76 |
58 |
$1K |
| D0602 |
|
116 |
116 |
$1K |
| D1351 |
Sealant - per tooth |
39 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
96 |
$784.66 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$462.00 |