| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,974 |
2,974 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
2,749 |
2,749 |
$57K |
| D1354 |
|
2,784 |
493 |
$48K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
637 |
378 |
$47K |
| D1351 |
Sealant - per tooth |
1,382 |
348 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,550 |
1,550 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,914 |
1,914 |
$21K |
| D1110 |
Prophylaxis - adult |
500 |
500 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,797 |
1,794 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,460 |
1,459 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
478 |
304 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
571 |
571 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
188 |
117 |
$10K |
| D0272 |
Bitewings - two radiographic images |
755 |
755 |
$9K |
| D0330 |
Panoramic radiographic image |
273 |
273 |
$8K |
| D0274 |
Bitewings - four radiographic images |
305 |
305 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
34 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
117 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
40 |
40 |
$949.00 |
| D0602 |
|
24 |
24 |
$0.00 |
| D0601 |
|
94 |
94 |
$0.00 |