| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,332 |
1,319 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,228 |
1,220 |
$32K |
| D1206 |
Topical application of fluoride varnish |
735 |
726 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
723 |
720 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
210 |
210 |
$10K |
| D0272 |
Bitewings - two radiographic images |
465 |
463 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
642 |
630 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
576 |
563 |
$8K |
| D1110 |
Prophylaxis - adult |
153 |
151 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
49 |
14 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
222 |
164 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$568.44 |