| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,091 |
1,090 |
$44K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
155 |
59 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,106 |
1,106 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
708 |
708 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
93 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
207 |
207 |
$13K |
| D0272 |
Bitewings - two radiographic images |
437 |
437 |
$12K |
| D0240 |
|
339 |
203 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
147 |
147 |
$6K |
| D1351 |
Sealant - per tooth |
148 |
43 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
176 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
45 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
16 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
15 |
$218.90 |