| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,762 |
1,762 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,339 |
2,339 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,287 |
2,287 |
$32K |
| D1110 |
Prophylaxis - adult |
200 |
200 |
$12K |
| D0272 |
Bitewings - two radiographic images |
336 |
336 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
15 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$312.00 |