| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
622 |
622 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
858 |
858 |
$24K |
| D1351 |
Sealant - per tooth |
429 |
116 |
$18K |
| D0274 |
Bitewings - four radiographic images |
617 |
617 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
215 |
122 |
$15K |
| D1110 |
Prophylaxis - adult |
266 |
266 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
220 |
138 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
814 |
813 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
97 |
53 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
612 |
612 |
$8K |
| D1206 |
Topical application of fluoride varnish |
278 |
278 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
78 |
49 |
$4K |
| D1354 |
|
70 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
112 |
112 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$513.10 |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
17 |
$484.50 |