| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,208 |
1,205 |
$80K |
| D1120 |
Prophylaxis - child |
1,702 |
1,699 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
524 |
523 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
434 |
190 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,160 |
1,155 |
$15K |
| D9993 |
|
242 |
242 |
$14K |
| D1310 |
|
313 |
313 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,179 |
758 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
173 |
173 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
428 |
428 |
$7K |
| D0603 |
|
297 |
297 |
$4K |
| D0274 |
Bitewings - four radiographic images |
187 |
187 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
283 |
280 |
$3K |
| D9430 |
|
95 |
94 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
15 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15 |
13 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
14 |
12 |
$1K |
| D4910 |
|
12 |
12 |
$924.00 |