| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,541 |
1,541 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,987 |
1,987 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,597 |
1,597 |
$24K |
| D1110 |
Prophylaxis - adult |
270 |
270 |
$15K |
| D1206 |
Topical application of fluoride varnish |
202 |
202 |
$6K |
| D0272 |
Bitewings - two radiographic images |
283 |
283 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
26 |
12 |
$4K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
44 |
$616.00 |