| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,240 |
1,240 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,118 |
1,118 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,369 |
1,369 |
$18K |
| D0272 |
Bitewings - two radiographic images |
938 |
938 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
983 |
979 |
$12K |
| D1351 |
Sealant - per tooth |
199 |
60 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
58 |
$6K |
| D0240 |
|
328 |
328 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
38 |
29 |
$4K |
| D1110 |
Prophylaxis - adult |
55 |
55 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
32 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
97 |
97 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
215 |
214 |
$2K |
| D1354 |
|
41 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
73 |
73 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
17 |
$898.70 |