| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,247 |
3,245 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
3,519 |
3,517 |
$100K |
| D0272 |
Bitewings - two radiographic images |
2,213 |
2,211 |
$34K |
| D1110 |
Prophylaxis - adult |
568 |
568 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,000 |
998 |
$22K |
| D1351 |
Sealant - per tooth |
760 |
219 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
95 |
$17K |
| D1206 |
Topical application of fluoride varnish |
695 |
694 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
56 |
12 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
166 |
$10K |
| D0274 |
Bitewings - four radiographic images |
222 |
222 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D0240 |
|
24 |
13 |
$528.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$200.00 |