| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0272 |
Bitewings - two radiographic images |
1,987 |
1,942 |
$132K |
| D0120 |
Periodic oral evaluation - established patient |
2,243 |
2,218 |
$102K |
| D1120 |
Prophylaxis - child |
3,446 |
3,393 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,251 |
1,230 |
$67K |
| D1206 |
Topical application of fluoride varnish |
3,279 |
3,232 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
2,800 |
2,717 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,382 |
2,511 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
594 |
154 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
220 |
91 |
$17K |
| D1351 |
Sealant - per tooth |
781 |
155 |
$16K |
| D0330 |
Panoramic radiographic image |
61 |
55 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
266 |
114 |
$10K |
| D2140 |
|
35 |
13 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$2K |
| D9420 |
|
12 |
12 |
$764.80 |