| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
278 |
278 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
314 |
314 |
$9K |
| D1206 |
Topical application of fluoride varnish |
155 |
155 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
241 |
236 |
$4K |
| D0274 |
Bitewings - four radiographic images |
146 |
146 |
$4K |
| D1351 |
Sealant - per tooth |
69 |
24 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
36 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
138 |
138 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
22 |
$1K |
| D1110 |
Prophylaxis - adult |
22 |
22 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
13 |
$912.00 |
| D0250 |
|
31 |
29 |
$802.75 |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$746.71 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
42 |
$676.02 |