| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
695 |
695 |
$29K |
| D1206 |
Topical application of fluoride varnish |
795 |
795 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
213 |
155 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
594 |
594 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
185 |
140 |
$10K |
| D1351 |
Sealant - per tooth |
483 |
155 |
$10K |
| D0330 |
Panoramic radiographic image |
179 |
179 |
$9K |
| D0274 |
Bitewings - four radiographic images |
273 |
273 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
183 |
$5K |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
235 |
235 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
17 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
81 |
$2K |
| D0272 |
Bitewings - two radiographic images |
92 |
92 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
23 |
16 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
144 |
$1K |
| D7111 |
|
18 |
14 |
$900.07 |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
15 |
$855.02 |