| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,325 |
1,325 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,260 |
1,260 |
$40K |
| D1206 |
Topical application of fluoride varnish |
578 |
578 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
792 |
792 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
773 |
773 |
$12K |
| D0272 |
Bitewings - two radiographic images |
503 |
503 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
659 |
659 |
$5K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
13 |
12 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
14 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |
| D0160 |
|
33 |
33 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12 |
12 |
$847.00 |
| D1320 |
|
12 |
12 |
$96.00 |
| D0601 |
|
73 |
73 |
$0.00 |
| D0602 |
|
13 |
13 |
$0.00 |