| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
356 |
356 |
$11K |
| D1206 |
Topical application of fluoride varnish |
470 |
469 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
77 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
330 |
330 |
$7K |
| D1351 |
Sealant - per tooth |
199 |
64 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
419 |
419 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
324 |
324 |
$3K |
| D1110 |
Prophylaxis - adult |
67 |
67 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
34 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
125 |
125 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
90 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
46 |
$971.52 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$659.84 |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$551.92 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$366.08 |
| D7111 |
|
16 |
14 |
$355.80 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$295.80 |