| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,563 |
1,563 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
747 |
461 |
$27K |
| D1206 |
Topical application of fluoride varnish |
941 |
941 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,145 |
1,145 |
$15K |
| D1351 |
Sealant - per tooth |
1,341 |
298 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
121 |
64 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
448 |
448 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
799 |
796 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
639 |
635 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
357 |
233 |
$6K |
| D0272 |
Bitewings - two radiographic images |
389 |
389 |
$5K |
| D1110 |
Prophylaxis - adult |
110 |
110 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
157 |
88 |
$4K |
| D0274 |
Bitewings - four radiographic images |
175 |
175 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
767 |
767 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
117 |
96 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
40 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
110 |
110 |
$2K |
| D0273 |
|
462 |
462 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$235.20 |