| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,717 |
1,717 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,398 |
2,398 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,353 |
2,353 |
$33K |
| D1110 |
Prophylaxis - adult |
208 |
208 |
$12K |
| D0272 |
Bitewings - two radiographic images |
432 |
432 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
31 |
25 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
32 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
28 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
26 |
$2K |
| D1351 |
Sealant - per tooth |
31 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
63 |
$730.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$128.00 |