| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,290 |
1,290 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,240 |
1,240 |
$26K |
| D0274 |
Bitewings - four radiographic images |
857 |
857 |
$22K |
| D1206 |
Topical application of fluoride varnish |
677 |
677 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
74 |
15 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
601 |
595 |
$7K |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
101 |
101 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
43 |
12 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
312 |
188 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$2K |