| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
478 |
478 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
450 |
450 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
462 |
462 |
$12K |
| D1351 |
Sealant - per tooth |
64 |
42 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
33 |
31 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
444 |
444 |
$3K |
| D0272 |
Bitewings - two radiographic images |
231 |
231 |
$3K |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
29 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
374 |
374 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
19 |
$1K |
| D2140 |
|
13 |
13 |
$618.80 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$554.48 |