| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
963 |
963 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
489 |
234 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,158 |
1,158 |
$31K |
| D0274 |
Bitewings - four radiographic images |
708 |
708 |
$20K |
| D1110 |
Prophylaxis - adult |
260 |
260 |
$14K |
| D1206 |
Topical application of fluoride varnish |
438 |
438 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,034 |
1,030 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
794 |
794 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
136 |
69 |
$7K |
| D0272 |
Bitewings - two radiographic images |
219 |
219 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25 |
14 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
170 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$1K |