| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,018 |
1,018 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
903 |
903 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,009 |
1,009 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
107 |
$26K |
| D0272 |
Bitewings - two radiographic images |
394 |
394 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
38 |
14 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
87 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
40 |
$1K |
| D0240 |
|
46 |
28 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$559.00 |