| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
429 |
428 |
$17K |
| D1351 |
Sealant - per tooth |
370 |
107 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
436 |
435 |
$12K |
| D0274 |
Bitewings - four radiographic images |
407 |
406 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
105 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
497 |
496 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
50 |
37 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
386 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
52 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
37 |
29 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
30 |
$2K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$1K |
| D1330 |
|
25 |
25 |
$0.00 |
| D1310 |
|
12 |
12 |
$0.00 |