| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,019 |
1,018 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,237 |
1,236 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
909 |
909 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
246 |
156 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
271 |
189 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
101 |
38 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
199 |
199 |
$9K |
| D0272 |
Bitewings - two radiographic images |
675 |
673 |
$7K |
| D1110 |
Prophylaxis - adult |
211 |
211 |
$7K |
| D0274 |
Bitewings - four radiographic images |
378 |
378 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
242 |
242 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
39 |
39 |
$1K |
| D1351 |
Sealant - per tooth |
49 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
227 |
227 |
$288.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$264.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$78.00 |