| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,080 |
2,080 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,892 |
2,892 |
$80K |
| D1110 |
Prophylaxis - adult |
1,454 |
1,454 |
$76K |
| D1206 |
Topical application of fluoride varnish |
2,404 |
2,404 |
$59K |
| D0272 |
Bitewings - two radiographic images |
1,912 |
1,912 |
$42K |
| D0330 |
Panoramic radiographic image |
478 |
478 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
269 |
191 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
198 |
139 |
$25K |
| D2740 |
Crown - porcelain/ceramic |
30 |
19 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
437 |
437 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
77 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$643.60 |